Provider Demographics
NPI:1780201483
Name:BEBOUT, RICHARD DOUG
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DOUG
Last Name:BEBOUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3248
Mailing Address - Country:US
Mailing Address - Phone:307-709-0290
Mailing Address - Fax:
Practice Address - Street 1:535 PIONEER AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3248
Practice Address - Country:US
Practice Address - Phone:307-709-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health