Provider Demographics
NPI:1275120446
Name:MADERA, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:MADERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1056
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-1056
Mailing Address - Country:US
Mailing Address - Phone:307-324-7156
Mailing Address - Fax:307-328-1651
Practice Address - Street 1:721 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5447
Practice Address - Country:US
Practice Address - Phone:307-324-7156
Practice Address - Fax:307-328-1651
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WYPPC-1287101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program