Basic Information
| Provider Information | |||||||||
| NPI: | 1679976054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCHHAMMER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MA, PPC | ||||||||
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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: | 09/30/2014 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | WY | N | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | PPC-878 | WY | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 106402908 | 05 | WY | MEDICAID | 106402907 | 05 | WY | MEDICAID |