Provider Demographics
NPI:1609361997
Name:LABOUNTA, RICKIE L (CAP)
Entity Type:Individual
Prefix:
First Name:RICKIE
Middle Name:L
Last Name:LABOUNTA
Suffix:
Gender:M
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 MADORA AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-3057
Mailing Address - Country:US
Mailing Address - Phone:307-358-2846
Mailing Address - Fax:307-358-1144
Practice Address - Street 1:1841 MADORA AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-3057
Practice Address - Country:US
Practice Address - Phone:307-358-2846
Practice Address - Fax:307-358-1144
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
WYCAP-174101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106402908Medicaid
WY106402907Medicaid