Provider Demographics
NPI:1518011618
Name:NORTHERN DDSP, INC.
Entity Type:Organization
Organization Name:NORTHERN DDSP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-254-2321
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-0966
Mailing Address - Country:US
Mailing Address - Phone:307-587-3571
Mailing Address - Fax:307-587-4897
Practice Address - Street 1:2044 STAMPEDE AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4917
Practice Address - Country:US
Practice Address - Phone:307-587-3571
Practice Address - Fax:307-587-4897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY116949100251B00000X
251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116949100Medicaid