Healthcare Provider Details

I. General information

NPI: 1801333646
Provider Name (Legal Business Name): BLAKE SPIEGELBERG MWS, PCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 COLLEGE MEADOWS DR
SHERIDAN WY
82801-9153
US

IV. Provider business mailing address

360 COLLEGE MEADOWS DR
SHERIDAN WY
82801-9153
US

V. Phone/Fax

Practice location:
  • Phone: 307-673-2510
  • Fax: 307-673-2513
Mailing address:
  • Phone: 307-673-2510
  • Fax: 307-673-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number663
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: