Provider Demographics
NPI:1457472748
Name:HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:HIGH COUNTRY BEHAVIORAL HEALTH
Other - Org Name:HIGH COUNTRY COUNSELING AND RESOURCE CENTERS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIPP
Authorized Official - Middle Name:L
Authorized Official - Last Name:DANA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-LAT
Authorized Official - Phone:307-885-9883
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-0376
Mailing Address - Country:US
Mailing Address - Phone:307-885-9883
Mailing Address - Fax:307-885-5206
Practice Address - Street 1:389 ADAMS ST.
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-0376
Practice Address - Country:US
Practice Address - Phone:307-885-9883
Practice Address - Fax:307-885-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207QA0401X, 261QR0405X, 291U00000X
WY405261QM0801X
WYLPC-550261QM0801X
WYLAT-220261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117699401Medicaid
WY117847400Medicaid