Provider Demographics
NPI:1689716227
Name:REHABILITATION ENTERPRISES OF NORTHEASTERN WYOMING
Entity Type:Organization
Organization Name:REHABILITATION ENTERPRISES OF NORTHEASTERN WYOMING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-672-7481
Mailing Address - Street 1:1969 S SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6108
Mailing Address - Country:US
Mailing Address - Phone:307-672-7481
Mailing Address - Fax:307-674-5117
Practice Address - Street 1:1969 S SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6108
Practice Address - Country:US
Practice Address - Phone:307-672-7481
Practice Address - Fax:307-674-5117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY709001103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty