Basic Information
Provider Information | |||||||||
NPI: | 1366440471 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STRAYER | ||||||||
FirstName: | CONNIE | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STUMP | ||||||||
OtherFirstName: | CONNIE | ||||||||
OtherMiddleName: | KAY | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1954 W MARIPOSA PKWY | ||||||||
Address2: |   | ||||||||
City: | WHEATLAND | ||||||||
State: | WY | ||||||||
PostalCode: | 822013102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073223190 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1954 W MARIPOSA PKWY | ||||||||
Address2: |   | ||||||||
City: | WHEATLAND | ||||||||
State: | WY | ||||||||
PostalCode: | 822013102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073223190 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 09/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 74 | WY | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 09 | WY | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 307577 | 01 | WY | BS | OTHER |