Basic Information
| Provider Information | |||||||||
| NPI: | 1386005437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYMAN | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5446 N ACADEMY BLVD STE 204 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195985555 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5446 N ACADEMY BLVD STE 204 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195985555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2016 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-19-39994 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.