Provider Demographics
NPI:1225257215
Name:PSYCHOLOGY CLINIC PC
Entity Type:Organization
Organization Name:PSYCHOLOGY CLINIC PC
Other - Org Name:THE PSYCHOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:DENISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-755-1000
Mailing Address - Street 1:217 S 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070
Mailing Address - Country:US
Mailing Address - Phone:307-755-1000
Mailing Address - Fax:307-755-9712
Practice Address - Street 1:217 S 1ST STREET
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070
Practice Address - Country:US
Practice Address - Phone:307-755-1000
Practice Address - Fax:307-755-9712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY276103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
307226Medicare UPIN
WY20249Medicare ID - Type Unspecified