Healthcare Provider Details

I. General information

NPI: 1629575253
Provider Name (Legal Business Name): FORTIS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1949 SUGARLAND DR STE 221
SHERIDAN WY
82801-5766
US

IV. Provider business mailing address

1949 SUGARLAND DR STE 221
SHERIDAN WY
82801-5766
US

V. Phone/Fax

Practice location:
  • Phone: 307-675-1275
  • Fax: 307-675-1276
Mailing address:
  • Phone: 307-675-1275
  • Fax: 307-675-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLCSW
License Number StateWY

VIII. Authorized Official

Name: ANDI K BELL
Title or Position: PROVIDER/OWNER
Credential: LCSW
Phone: 307-675-1275