Basic Information
Provider Information | |||||||||
NPI: | 1134890650 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HIGH COUNTRY BEHAVIORAL HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 376 | ||||||||
Address2: |   | ||||||||
City: | AFTON | ||||||||
State: | WY | ||||||||
PostalCode: | 831100376 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077894224 | ||||||||
FaxNumber: | 3077894225 | ||||||||
Practice Location | |||||||||
Address1: | 1841 MADORA AVE | ||||||||
Address2: |   | ||||||||
City: | DOUGLAS | ||||||||
State: | WY | ||||||||
PostalCode: | 826333057 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073582846 | ||||||||
FaxNumber: | 3077894225 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2021 | ||||||||
LastUpdateDate: | 06/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEWMAN | ||||||||
AuthorizedOfficialFirstName: | SHEILA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE OPERATIONS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3077894224 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QA0401X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 291U00000X |   |   | N |   | Laboratories | Clinical Medical Laboratory |   | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.