Provider Demographics
NPI:1144613134
Name:BALES, DEMETRIA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:BALES
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ROAD 6PR
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-5700
Mailing Address - Country:US
Mailing Address - Phone:541-404-4900
Mailing Address - Fax:
Practice Address - Street 1:702 PLATINUM AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3423
Practice Address - Country:US
Practice Address - Phone:307-213-9954
Practice Address - Fax:307-275-9843
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL122011041C0700X
WYLCSW-12761041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator