Basic Information
| Provider Information | |||||||||
| NPI: | 1457593345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTROSS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 E 18TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076333044 | ||||||||
| FaxNumber: | 3076337256 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 E. 18TH STREET | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076333044 | ||||||||
| FaxNumber: | 3076337256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
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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 | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LCSW 704 | 01 | WY | LICENSE | OTHER | 1457593345 | 05 | WY | MEDICAID |