Basic Information
| Provider Information | |||||||||
| NPI: | 1134401227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FREMONT COUNSELING SERVICE | ||||||||
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| 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: | 09/14/2011 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3073322231 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | W9054 | 01 | WY | MEDICARE ID- TYPE UNSPECIFIED | OTHER |