Provider Demographics
NPI:1740540061
Name:PAYETTE, MILDRED LOUISE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:LOUISE
Last Name:PAYETTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MIDGE
Other - Middle Name:
Other - Last Name:PAYETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5000 BLACKMORE RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3345
Mailing Address - Country:US
Mailing Address - Phone:307-233-6000
Mailing Address - Fax:307-233-6089
Practice Address - Street 1:5000 BLACKMORE RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3345
Practice Address - Country:US
Practice Address - Phone:307-233-6000
Practice Address - Fax:307-233-6089
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-931104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW27921Medicare PIN