Provider Demographics
NPI:1154626711
Name:DOKKEN, CLAY WILLIAM (PPC)
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:WILLIAM
Last Name:DOKKEN
Suffix:
Gender:M
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 SAGEBRUSH AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4437
Mailing Address - Country:US
Mailing Address - Phone:307-287-5141
Mailing Address - Fax:
Practice Address - Street 1:400 S KENDRICK AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3848
Practice Address - Country:US
Practice Address - Phone:307-685-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1336101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY133683500Medicare PIN