Basic Information
| Provider Information | |||||||||
| NPI: | 1225257215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOLOGY CLINIC PC | ||||||||
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| OtherOrganizationName: | THE PSYCHOLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 S 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077551000 | ||||||||
| FaxNumber: | 3077559712 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 S 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077551000 | ||||||||
| FaxNumber: | 3077559712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DENISON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3077551000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 276 | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.