Provider Demographics
NPI:1821297102
Name:CAROLJEAN BONGO PSYD LLC
Entity Type:Organization
Organization Name:CAROLJEAN BONGO PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLJEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONGO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:307-760-1871
Mailing Address - Street 1:PO BOX 21270
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7025
Mailing Address - Country:US
Mailing Address - Phone:307-760-1871
Mailing Address - Fax:866-621-1893
Practice Address - Street 1:2909 BENT AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2742
Practice Address - Country:US
Practice Address - Phone:307-760-1871
Practice Address - Fax:866-621-1893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY432103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124350100Medicaid
WY124350100Medicaid