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General NPI Number Information
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NPI Number | 1679027155
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Entity Type | Organization
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Legal Business Name | CLEAR CREEK COMPANY LLC
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Dates
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Enumeration Date | 08/12/2016
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Last Update Date | 08/12/2016
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Provider Practice Location Address
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Address Line | 63 N BURRITT AVE
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City | BUFFALO
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State | WY
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Zip | 82834-1868
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Country | US
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Telephone | 307-337-8247
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 69
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City | BUFFALO
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State | WY
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Zip | 82834-0069
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Country | US
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Telephone | 307-337-8247
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Fax |
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Authorized Official
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Title or Position | OWNER MEMBER
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Name | ADELAIDE WILSON
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Credential |
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Telephone | 307-337-8247
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 145
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License Number State | WY
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