Healthcare Provider Details

I. General information

NPI: 1184176430
Provider Name (Legal Business Name): MAGELLAN HEALTHCARE OF WYOMING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E MADISON AVE STE 6
RIVERTON WY
82501-4712
US

IV. Provider business mailing address

625 E MADISON AVE STE 6
RIVERTON WY
82501-4712
US

V. Phone/Fax

Practice location:
  • Phone: 307-851-3955
  • Fax:
Mailing address:
  • Phone: 307-851-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateWY

VIII. Authorized Official

Name: LINDA HERON
Title or Position: MANAGING DIRECTOR
Credential: M.D.
Phone: 307-851-3955