Provider Demographics
NPI:1407230766
Name:TBT, LLC
Entity Type:Organization
Organization Name:TBT, LLC
Other - Org Name:TETON BEHAVIOR THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADOF
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-734-6040
Mailing Address - Street 1:PO BOX 2299
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-2299
Mailing Address - Country:US
Mailing Address - Phone:307-734-6040
Mailing Address - Fax:307-734-6040
Practice Address - Street 1:480 S CACHE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8222
Practice Address - Country:US
Practice Address - Phone:307-734-6040
Practice Address - Fax:307-734-6040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-837251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY137887200Medicaid