Provider Demographics
NPI:1083941389
Name:BADER, TODD (MA,LPC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:BADER
Suffix:
Gender:M
Credentials:MA,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-0492
Mailing Address - Country:US
Mailing Address - Phone:307-799-8640
Mailing Address - Fax:307-789-2866
Practice Address - Street 1:724 FRONT ST
Practice Address - Street 2:SUITE 511
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82931
Practice Address - Country:US
Practice Address - Phone:307-799-8640
Practice Address - Fax:307-789-2866
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY512101YA0400X, 101YP2500X
WYLPC-519101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional