Provider Demographics
NPI:1609914811
Name:NORWOOD, KELLY M
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:NORWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 17 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ARAPAHOE
Mailing Address - State:WY
Mailing Address - Zip Code:82510-9141
Mailing Address - Country:US
Mailing Address - Phone:307-332-6471
Mailing Address - Fax:307-332-6471
Practice Address - Street 1:376 17 MILE RD
Practice Address - Street 2:
Practice Address - City:ARAPAHOE
Practice Address - State:WY
Practice Address - Zip Code:82510-9141
Practice Address - Country:US
Practice Address - Phone:307-332-6471
Practice Address - Fax:307-332-6471
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115740000Medicaid