Provider Demographics
NPI:1093005803
Name:THE CLINIC FOR MENTAL HEALTH & WELLNESS
Entity Type:Organization
Organization Name:THE CLINIC FOR MENTAL HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NESSLNGER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:307-755-1000
Mailing Address - Street 1:504 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3704
Mailing Address - Country:US
Mailing Address - Phone:307-755-1000
Mailing Address - Fax:307-742-9717
Practice Address - Street 1:504 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3704
Practice Address - Country:US
Practice Address - Phone:307-755-1000
Practice Address - Fax:307-742-9717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC#1027101Y00000X
WYLPC#290101Y00000X
WYLAT#265101YA0400X
WYLCSW#1761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty