Provider Demographics
NPI:1659672616
Name:SUMMIT PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:SUMMIT PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLANEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:307-684-9360
Mailing Address - Street 1:182 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1727
Mailing Address - Country:US
Mailing Address - Phone:307-684-9360
Mailing Address - Fax:307-684-5187
Practice Address - Street 1:182 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1727
Practice Address - Country:US
Practice Address - Phone:307-684-9360
Practice Address - Fax:307-684-5187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY328103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117880601Medicaid