=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730608910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICIA RUTH NESBIT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2017
-----------------------------------------------------
Last Update Date | 09/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 S GILLETTE AVE
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-685-8182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S GILLETTE AVE
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAN NESBIT
-----------------------------------------------------
Credential | OFFICE MANAGER
-----------------------------------------------------
Telephone | 307-685-8182
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-1146
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LAT-321
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------