Provider Demographics
NPI:1366658601
Name:BIG HORN BASIN MENTAL HEALTH GROUP
Entity Type:Organization
Organization Name:BIG HORN BASIN MENTAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GIBSON
Authorized Official - Middle Name:B
Authorized Official - Last Name:CONDIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-754-3860
Mailing Address - Street 1:1054 VALI RD
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-9259
Mailing Address - Country:US
Mailing Address - Phone:307-754-3860
Mailing Address - Fax:
Practice Address - Street 1:1054 VALI RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-9259
Practice Address - Country:US
Practice Address - Phone:307-754-3860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP03103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124068400Medicaid