=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558411025
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL J BJORNSON PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 10/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 HOUSE AVE SUITE 201
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82001-3176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-638-7757
-----------------------------------------------------
Fax | 307-638-8359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 20970
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82003-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-638-7757
-----------------------------------------------------
Fax | 307-638-8359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 346718-2501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 465
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------