Provider Demographics
NPI:1932273794
Name:DIMITRIJEVIC, ALEX (MA)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:DIMITRIJEVIC
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3704
Mailing Address - Country:US
Mailing Address - Phone:307-755-1000
Mailing Address - Fax:307-742-9717
Practice Address - Street 1:502 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3704
Practice Address - Country:US
Practice Address - Phone:307-755-1000
Practice Address - Fax:307-742-9717
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1754101YM0800X
WYWY LPC-674A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY314626OtherBLUE CROSS BLUE SHEILD