Healthcare Provider Details

I. General information

NPI: 1831442201
Provider Name (Legal Business Name): REGION V BOARD OF COOPERATIVE EDUCATIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 NORTH WILDERNESS DRIVE
WILSON WY
83025
US

IV. Provider business mailing address

PO BOX 240
WILSON WY
83014-0240
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-8210
  • Fax: 307-733-8462
Mailing address:
  • Phone: 307-733-8210
  • Fax: 307-733-8462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberOTR598
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberOTR598
License Number StateWY

VIII. Authorized Official

Name: MS. MAYLING H SUMICAD
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 307-733-8210