Basic Information
| Provider Information | |||||||||
| NPI: | 1225003023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOLUTIONS FOR LIFE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EASTERN WYOMING MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1841 MADORA AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826333057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582846 | ||||||||
| FaxNumber: | 3073585329 | ||||||||
| Practice Location | |||||||||
| Address1: | 1841 MADORA AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826333057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582846 | ||||||||
| FaxNumber: | 3073585329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3073582846 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | CERTIFIED | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 106402904 | 05 | WY | MEDICAID | 106402900 | 05 | WY | MEDICAID | 106402903 | 05 | WY | MEDICAID | 106402905 | 05 | WY | MEDICAID | 106402908 | 05 | WY | MEDICAID | 106402907 | 05 | WY | MEDICAID |