Provider Demographics
NPI:1306406509
Name:KINTSUGI PSYCHIATRY, LLC
Entity Type:Organization
Organization Name:KINTSUGI PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MADETZKE
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:307-333-5757
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82602-1117
Mailing Address - Country:US
Mailing Address - Phone:307-333-5757
Mailing Address - Fax:307-439-2141
Practice Address - Street 1:145 S DURBIN ST STE 108
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2566
Practice Address - Country:US
Practice Address - Phone:307-333-5757
Practice Address - Fax:307-439-2141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-19
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1306406509Medicaid
WY1093117210Medicaid