Basic Information
Provider Information | |||||||||
NPI: | 1932229523 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOLUTIONS FOR LIFE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EASTERN WYOMING MENTAL HEALTH | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 03/29/2007 | ||||||||
LastUpdateDate: | 02/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | 261QR0405X |   | WY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 106402905 | 05 | WY |   | MEDICAID | 106402904 | 05 | WY |   | MEDICAID | 106402907 | 05 | WY |   | MEDICAID | 106402908 | 05 | WY |   | MEDICAID | 106402903 | 05 | WY |   | MEDICAID | 106402900 | 05 | WY |   | MEDICAID |