Provider Demographics
NPI:1861815581
Name:BRYAN BENJAMIN COLLINS III
Entity Type:Organization
Organization Name:BRYAN BENJAMIN COLLINS III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:III
Authorized Official - Credentials:MSW
Authorized Official - Phone:307-472-9890
Mailing Address - Street 1:907 N POPLAR ST STE 183
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1304
Mailing Address - Country:US
Mailing Address - Phone:307-472-9890
Mailing Address - Fax:307-472-9891
Practice Address - Street 1:907 N POPLAR ST STE 183
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1304
Practice Address - Country:US
Practice Address - Phone:307-472-9890
Practice Address - Fax:307-472-9891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-5241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty