=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154806917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHEYENNE LYN SYVERTSON-HAGESTUEN MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2018
-----------------------------------------------------
Last Update Date | 09/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S CACHE STREET
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83001-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-733-7946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2631
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83001-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-733-7946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 801
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------