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General NPI Number Information
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NPI Number | 1043644545
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Entity Type | Organization
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Legal Business Name | BIG HORN BASIN ASSOCIATION ADOLESCENT PROGRAMS
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Dates
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Enumeration Date | 09/03/2013
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Last Update Date | 09/03/2013
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Provider Practice Location Address
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Address Line | 967 HWY 20 SOUTH
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City | BASIN
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State | WY
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Zip | 82410
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Country | US
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Telephone | 307-568-2222
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Fax | 307-568-2982
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Provider Business Mailing Address
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Address Line | PO BOX 858
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City | BASIN
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State | WY
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Zip | 82410-0858
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Country | US
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Telephone | 307-568-2222
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Fax | 307-568-2982
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. BROCK GREEK
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Credential | LCSW
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Telephone | 307-568-2222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number | 1708G
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License Number State | WY
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