Provider Demographics
NPI:1093090656
Name:NORTHERN WYOMING MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:NORTHERN WYOMING MENTAL HEALTH CENTER, INC.
Other - Org Name:VOLUNTEERS OF AMERICA NORTHERN ROCKIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF IT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-684-5531
Mailing Address - Street 1:1701 W 5TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2748
Mailing Address - Country:US
Mailing Address - Phone:307-674-5534
Mailing Address - Fax:307-672-9302
Practice Address - Street 1:1876 S SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6136
Practice Address - Country:US
Practice Address - Phone:307-672-0475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW4370109Medicare PIN