Provider Demographics
NPI:1497008957
Name:BACON, BELINDA (PCSW)
Entity Type:Individual
Prefix:
First Name:BELINDA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4989 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-9548
Mailing Address - Country:US
Mailing Address - Phone:307-745-8997
Mailing Address - Fax:
Practice Address - Street 1:4989 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-9548
Practice Address - Country:US
Practice Address - Phone:307-745-8997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY475-PCSW101Y00000X
WYPCSW-475104100000X
WYLCSW-9821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLCSW-982OtherSTATE LICENSE
WY475-PCSWOtherSTATE LICENSE