Basic Information
| Provider Information | |||||||||
| NPI: | 1215936851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEAVITT | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2310 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076326435 | ||||||||
| FaxNumber: | 3076357982 | ||||||||
| Practice Location | |||||||||
| Address1: | 2310 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076326435 | ||||||||
| FaxNumber: | 3076357982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
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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 | 101Y00000X | 279 | WY | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 313508 | 01 | WY | BS | OTHER |