Basic Information
Provider Information | |||||||||
NPI: | 1073786844 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RENFRO | ||||||||
FirstName: | ELAINE | ||||||||
MiddleName: | DOTY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSCSW , LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 20970 | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820037020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076371600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2600 E 18TH ST | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820015511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076371600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2008 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3605 | KS | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 2007000625 | MO | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW-623 | WY | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.