Provider Demographics
NPI:1851512750
Name:HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:HIGH COUNTRY BEHAVIORAL HEALTH
Other - Org Name:WELLSPRING COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICE (CEO)
Authorized Official - Prefix:
Authorized Official - First Name:KIPP
Authorized Official - Middle Name:
Authorized Official - Last Name:DANA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:307-885-9883
Mailing Address - Street 1:121 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2634
Mailing Address - Country:US
Mailing Address - Phone:307-864-3138
Mailing Address - Fax:307-864-3139
Practice Address - Street 1:121 S 4TH ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2634
Practice Address - Country:US
Practice Address - Phone:307-864-3138
Practice Address - Fax:307-864-3139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY108969205Medicaid
WY108969203Medicaid