Provider Demographics
NPI:1336473859
Name:BIG HORN PSYCHOLOGICAL SERVICES LC
Entity Type:Organization
Organization Name:BIG HORN PSYCHOLOGICAL SERVICES LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:307-675-1805
Mailing Address - Street 1:PO BOX 1035
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-1035
Mailing Address - Country:US
Mailing Address - Phone:307-675-1805
Mailing Address - Fax:
Practice Address - Street 1:339 W LOUCKS ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4121
Practice Address - Country:US
Practice Address - Phone:307-675-1805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty