Provider Demographics
NPI:1568612380
Name:DIM, LEYLA (LPC)
Entity Type:Individual
Prefix:
First Name:LEYLA
Middle Name:
Last Name:DIM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2444
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-2444
Mailing Address - Country:US
Mailing Address - Phone:307-587-6288
Mailing Address - Fax:
Practice Address - Street 1:331 ROBERT ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9268
Practice Address - Country:US
Practice Address - Phone:307-587-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY133438700Medicaid