Basic Information
| Provider Information | |||||||||
| NPI: | 1497008957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACON | ||||||||
| FirstName: | BELINDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4989 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820729548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458997 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4989 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820729548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458997 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2012 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 475-PCSW | WY | N | Behavioral Health & Social Service Providers | Counselor | 104100000X | PCSW-475 | WY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LCSW-982 | WY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LCSW-982 | 01 | WY | STATE LICENSE | OTHER | 475-PCSW | 01 | WY | STATE LICENSE | OTHER |