=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255458295
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL A. PASTORE-WATKINS PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 12/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 W 5TH ST
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-674-4405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1221 W 5TH ST
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-674-4405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 304
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------