Basic Information
Provider Information | |||||||||
NPI: | 1033206289 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CATHEDRAL HOME FOR CHILDREN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4989 N 3RD ST | ||||||||
Address2: |   | ||||||||
City: | LARAMIE | ||||||||
State: | WY | ||||||||
PostalCode: | 820729548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077458997 | ||||||||
FaxNumber: | 3077426146 | ||||||||
Practice Location | |||||||||
Address1: | 4989 N 3RD ST | ||||||||
Address2: |   | ||||||||
City: | LARAMIE | ||||||||
State: | WY | ||||||||
PostalCode: | 820729548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077458997 | ||||||||
FaxNumber: | 3077426146 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2006 | ||||||||
LastUpdateDate: | 03/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAUSER | ||||||||
AuthorizedOfficialFirstName: | NICOLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3077458997 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
NPICertificationDate: | 03/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   | 101YP2500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 320800000X |   |   | N |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   | 323P00000X |   |   | N |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   | 3245S0500X |   |   | N |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 385HR2055X |   |   | N |   | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 10026747700 | 05 | NE |   | MEDICAID |