Provider Demographics
NPI:1104793165
Name:EID, ALPHONSE
Entity type:Individual
Prefix:
First Name:ALPHONSE
Middle Name:
Last Name:EID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3801
Mailing Address - Country:US
Mailing Address - Phone:307-381-8351
Mailing Address - Fax:
Practice Address - Street 1:107 E 1ST ST
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3801
Practice Address - Country:US
Practice Address - Phone:307-381-8351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health