Basic Information
| Provider Information | |||||||||
| NPI: | 1316458540 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASHLEE MICKELSON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820703720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072723515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 504 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820703704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077551000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2017 | ||||||||
| LastUpdateDate: | 10/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | MICKELSON | ||||||||
| AuthorizedOfficialFirstName: | ASHLEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 3072723515 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | LCSW-820 | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.