Basic Information
| Provider Information | |||||||||
| NPI: | 1043399116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLECCHIA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2526 SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076349653 | ||||||||
| FaxNumber: | 3076388256 | ||||||||
| Practice Location | |||||||||
| Address1: | 2526 SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076349653 | ||||||||
| FaxNumber: | 3076388256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 04/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 392 | WY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 18753 | MN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 312188 | 01 | WY | BS OF WY | OTHER |