Healthcare Provider Details

I. General information

NPI: 1093090656
Provider Name (Legal Business Name): NORTHERN WYOMING MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 08/11/2023
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1876 S SHERIDAN AVE
SHERIDAN WY
82801-6136
US

IV. Provider business mailing address

1701 W 5TH ST SUITE C
SHERIDAN WY
82801-2748
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-0475
  • Fax:
Mailing address:
  • Phone: 307-674-5534
  • Fax: 307-672-9302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateWY

VIII. Authorized Official

Name: KELLY BUCKINGHAM
Title or Position: VP OF IT
Credential:
Phone: 307-684-5531