Provider Demographics
NPI:1043644545
Name:BIG HORN BASIN ASSOCIATION ADOLESCENT PROGRAMS
Entity Type:Organization
Organization Name:BIG HORN BASIN ASSOCIATION ADOLESCENT PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-568-2222
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410-0858
Mailing Address - Country:US
Mailing Address - Phone:307-568-2222
Mailing Address - Fax:307-568-2982
Practice Address - Street 1:967 HWY 20 SOUTH
Practice Address - Street 2:
Practice Address - City:BASIN
Practice Address - State:WY
Practice Address - Zip Code:82410
Practice Address - Country:US
Practice Address - Phone:307-568-2222
Practice Address - Fax:307-568-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1708G253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency