Provider Demographics
NPI:1831442201
Name:REGION V BOARD OF COOPERATIVE EDUCATIONAL SERVICES
Entity type:Organization
Organization Name:REGION V BOARD OF COOPERATIVE EDUCATIONAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MAYLING
Authorized Official - Middle Name:H
Authorized Official - Last Name:SUMICAD
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:307-733-8210
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-0240
Mailing Address - Country:US
Mailing Address - Phone:307-733-8210
Mailing Address - Fax:307-733-8462
Practice Address - Street 1:3850 NORTH WILDERNESS DRIVE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83025
Practice Address - Country:US
Practice Address - Phone:307-733-8210
Practice Address - Fax:307-733-8462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR598322D00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children