Healthcare Provider Details

I. General information

NPI: 1184854689
Provider Name (Legal Business Name): MOUNTAINS EDGE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W LOUCKS ST
SHERIDAN WY
82801-4129
US

IV. Provider business mailing address

406 W LOUCKS ST
SHERIDAN WY
82801-4129
US

V. Phone/Fax

Practice location:
  • Phone: 307-673-4647
  • Fax: 307-674-1724
Mailing address:
  • Phone: 307-673-4647
  • Fax: 307-674-1724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberLPC 790
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License NumberLPC-790
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLAT - 294
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberLPC - 790
License Number StateWY
# 5
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC - 790
License Number StateWY

VIII. Authorized Official

Name: MS. JENNIFER B JONES-ROBINSON
Title or Position: OWNER
Credential: LPC, LAT,MAC
Phone: 307-673-4647