Provider Demographics
NPI:1659516318
Name:TETON PSYCHOLOGY CLINIC, LLC
Entity Type:Organization
Organization Name:TETON PSYCHOLOGY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:LAAKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-690-9836
Mailing Address - Street 1:PO BOX 3143
Mailing Address - Street 2:460 SOUTH CACHE STREET
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-3143
Mailing Address - Country:US
Mailing Address - Phone:307-690-9836
Mailing Address - Fax:307-739-4522
Practice Address - Street 1:460 SOUTH CACHE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-690-9836
Practice Address - Fax:307-739-4522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY399261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health