Provider Demographics
NPI:1366645384
Name:MARTENSON, CAROL R
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:R
Last Name:MARTENSON
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 1:721 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3423
Mailing Address - Country:US
Mailing Address - Phone:307-578-2288
Mailing Address - Fax:
Practice Address - Street 1:721 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3423
Practice Address - Country:US
Practice Address - Phone:307-578-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-680101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLPC-680OtherSTATE LICENSE