Basic Information
| Provider Information | |||||||||
| NPI: | 1154491645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA LPC LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2310 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076346433 | ||||||||
| FaxNumber: | 3076357982 | ||||||||
| Practice Location | |||||||||
| Address1: | 2310 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076346433 | ||||||||
| FaxNumber: | 3076357982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 04/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 182 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.