Provider Demographics
NPI:1003220096
Name:BRAIN INJURY ALLIANCE OF WYOMING
Entity Type:Organization
Organization Name:BRAIN INJURY ALLIANCE OF WYOMING
Other - Org Name:BRAIN INJURY ASSOCIATION OF WYOMING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LACKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-473-1767
Mailing Address - Street 1:111 W 2ND ST STE 106
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2458
Mailing Address - Country:US
Mailing Address - Phone:307-473-1767
Mailing Address - Fax:307-237-5222
Practice Address - Street 1:111 W 2ND ST STE 106
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2458
Practice Address - Country:US
Practice Address - Phone:307-473-1767
Practice Address - Fax:307-237-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services