Basic Information
| Provider Information | |||||||||
| NPI: | 1003812694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FREMONT COUNSELING SERVICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 748 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322231 | ||||||||
| FaxNumber: | 3073329338 | ||||||||
| Practice Location | |||||||||
| Address1: | 748 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322231 | ||||||||
| FaxNumber: | 3073329338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 02/04/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3073322231 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 171M00000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 106088104 | 05 | WY | MEDICAID | 106088107 | 05 | WY | MEDICAID | 106088100 | 05 | WY | MEDICAID | 106088106 | 05 | WY | MEDICAID |