MEDICARE: ABINTRA PSYCHOLOGICAL ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	#268	WY

General Provider Information

NPI Number	:	1710122908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABINTRA PSYCHOLOGICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	135 PINE ST STE B
Second Line	:	PO BOX 1222
City	:	BUFFALO
State	:	WY
Zip	:	82834-2332
Country	:	US
Telephone Number	:	307-684-5828
Fax Number	:	307-684-5803

Provider Business Practice Location Address
First Line	:	135 PINE ST STE B
Second Line	:
City	:	BUFFALO
State	:	WY
Zip	:	82834-2332
Country	:	US
Telephone Number	:	307-684-5828
Fax Number	:	307-684-5803

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THERESA A FAULKNER
Credential	:	PH.D.
Telephone Number	:	307-684-5828

Provider Enumeration Date	:	12/02/2008
Last Update Date	:	12/02/2008

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