Provider Demographics
NPI:1477022804
Name:WHITLOCK, BREMEN TAYLOR
Entity Type:Individual
Prefix:
First Name:BREMEN
Middle Name:TAYLOR
Last Name:WHITLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1856 HARRISON ST APT B6
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-6398
Mailing Address - Country:US
Mailing Address - Phone:307-340-2072
Mailing Address - Fax:
Practice Address - Street 1:3120 OLD FAITHFUL RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5865
Practice Address - Country:US
Practice Address - Phone:307-369-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician