Provider Demographics
NPI:1376700351
Name:NORTHWEST WYOMING TREATMENT CENTER
Entity Type:Organization
Organization Name:NORTHWEST WYOMING TREATMENT CENTER
Other - Org Name:VERNON CLEGG CONDIE YOUTH HOMES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-271-7460
Mailing Address - Street 1:1106 JULIE LN
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-1632
Mailing Address - Country:US
Mailing Address - Phone:307-271-7460
Mailing Address - Fax:
Practice Address - Street 1:1106 JULIE LN
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-1632
Practice Address - Country:US
Practice Address - Phone:307-271-7460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children