Provider Demographics
NPI:1952679003
Name:COLCLOUGH, KAREN BETH
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:BETH
Last Name:COLCLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4259
Mailing Address - Street 2:140 EAST BROADWAY
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4259
Mailing Address - Country:US
Mailing Address - Phone:307-733-7637
Mailing Address - Fax:307-733-7675
Practice Address - Street 1:2441 PECK AVE.
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-733-7637
Practice Address - Fax:307-733-7675
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171MOOOOOX171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator