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General NPI Number Information
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NPI Number | 1659516318
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Entity Type | Organization
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Legal Business Name | TETON PSYCHOLOGY CLINIC, LLC
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Dates
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Enumeration Date | 12/10/2008
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Last Update Date | 12/10/2008
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Provider Practice Location Address
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Address Line | 460 SOUTH CACHE STREET
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City | JACKSON
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State | WY
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Zip | 83001
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Country | US
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Telephone | 307-690-9836
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Fax | 307-739-4522
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Provider Business Mailing Address
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Address Line | PO BOX 3143 460 SOUTH CACHE STREET
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City | JACKSON
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State | WY
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Zip | 83001-3143
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Country | US
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Telephone | 307-690-9836
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Fax | 307-739-4522
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. WENDY ELAINE LAAKMANN
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Credential | PH.D.
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Telephone | 307-690-9836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 399
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License Number State | WY
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