Provider Demographics
NPI:1457713885
Name:ANTELOPE, REGINA GALE X (AAA, CAP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:GALE
Last Name:ANTELOPE
Suffix:X
Gender:F
Credentials:AAA, CAP
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 1989
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0240
Mailing Address - Country:US
Mailing Address - Phone:307-857-9468
Mailing Address - Fax:307-333-0447
Practice Address - Street 1:10269 HWY 789
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-857-9468
Practice Address - Fax:307-333-0447
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYC.A.P. 033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)