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General NPI Number Information
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NPI Number | 1659672616
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Entity Type | Organization
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Legal Business Name | SUMMIT PSYCHOLOGICAL SERVICES LLC
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Dates
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Enumeration Date | 11/08/2010
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Last Update Date | 11/08/2010
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Provider Practice Location Address
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Address Line | 182 N MAIN ST
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City | BUFFALO
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State | WY
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Zip | 82834-1727
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Country | US
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Telephone | 307-684-9360
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Fax | 307-684-5187
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Provider Business Mailing Address
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Address Line | 182 N MAIN ST
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City | BUFFALO
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State | WY
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Zip | 82834-1727
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Country | US
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Telephone | 307-684-9360
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Fax | 307-684-5187
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIMOTHY A BLANEY
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Credential | PSYD
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Telephone | 307-684-9360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 328
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License Number State | WY
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