Provider Demographics
NPI:1356486245
Name:PETREN, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:PETREN
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 6005
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-6005
Mailing Address - Country:US
Mailing Address - Phone:307-789-3710
Mailing Address - Fax:307-789-0823
Practice Address - Street 1:50 ALLEGIANCE CIR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3804
Practice Address - Country:US
Practice Address - Phone:307-789-3710
Practice Address - Fax:307-789-0823
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY424103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121776300Medicaid