Provider Demographics
NPI:1033342613
Name:DANIEL COSSABOON PRIVATE PRACTICE LLC
Entity Type:Organization
Organization Name:DANIEL COSSABOON PRIVATE PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SEIKI
Authorized Official - Last Name:COSSABOON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:307-250-7527
Mailing Address - Street 1:1001 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3745
Mailing Address - Country:US
Mailing Address - Phone:307-250-7527
Mailing Address - Fax:
Practice Address - Street 1:1001 14TH ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3745
Practice Address - Country:US
Practice Address - Phone:307-250-7527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health