Provider Demographics
NPI:1134220189
Name:BONGO, CAROLJEAN (PSYD)
Entity type:Individual
Prefix:
First Name:CAROLJEAN
Middle Name:
Last Name:BONGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CAROLJEAN
Other - Middle Name:
Other - Last Name:BONGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY432103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124350100Medicaid
WY21418Medicare PIN