1164783916 NPI number — SPECIALTY COUNSELING

Table of content: (NPI 1164783916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164783916 NPI number — SPECIALTY COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALTY COUNSELING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164783916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4025 RAWLINS ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-424-7986
Provider Business Mailing Address Fax Number:
307-426-4799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4025 RAWLINS ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-424-7986
Provider Business Practice Location Address Fax Number:
307-426-4799
Provider Enumeration Date:
06/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COWPER
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MENTAL HEALTH COUNSELING
Authorized Official Telephone Number:
307-399-0575

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  PPC-581 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2CF879B33D , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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