Provider Demographics
NPI:1063829976
Name:BLAYRE-WHITE, SUE (MS, LAT, NCACII, DOT)
Entity Type:Individual
Prefix:MS
First Name:SUE
Middle Name:
Last Name:BLAYRE-WHITE
Suffix:
Gender:F
Credentials:MS, LAT, NCACII, DOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 22049
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003
Mailing Address - Country:US
Mailing Address - Phone:307-275-0423
Mailing Address - Fax:307-432-4038
Practice Address - Street 1:1623 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-275-0423
Practice Address - Fax:307-432-4038
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-346101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)