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General NPI Number Information
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NPI Number | 1134220189
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Entity Type | Individual
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Provider Name | CAROLJEAN BONGO PSYD
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Gender | Female
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2909 BENT AVE
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City | CHEYENNE
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State | WY
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Zip | 82001-2742
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Country | US
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Telephone | 307-760-1871
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Fax | 866-621-1893
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Provider Business Mailing Address
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Address Line | PO BOX 21270
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City | CHEYENNE
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State | WY
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Zip | 82003-7025
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Country | US
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Telephone | 307-760-1871
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Fax | 866-621-1893
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 432
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License Number State | WY
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