Provider Demographics
NPI:1891099545
Name:HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:HIGH COUNTRY BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KIPP
Authorized Official - Middle Name:L
Authorized Official - Last Name:DANA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LAT
Authorized Official - Phone:307-885-9883
Mailing Address - Street 1:75 YELLOW CREEK RD.
Mailing Address - Street 2:STE 105
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5205
Mailing Address - Country:US
Mailing Address - Phone:307-789-4224
Mailing Address - Fax:307-789-4225
Practice Address - Street 1:190 OVERTHRUST RD
Practice Address - Street 2:STE 105
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5205
Practice Address - Country:US
Practice Address - Phone:307-789-4224
Practice Address - Fax:307-789-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207QA0401X, 291U00000X
WY251S00000X
WYLPC-550261QM0801X
WYLAT-220261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117847400Medicaid