Basic Information
| Provider Information | |||||||||
| NPI: | 1457713885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTELOPE | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | GALE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | X | ||||||||
| Credential: | AAA, C.A.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1989 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825010240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078579468 | ||||||||
| FaxNumber: | 3073330447 | ||||||||
| Practice Location | |||||||||
| Address1: | 10269 HWY 789 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078579468 | ||||||||
| FaxNumber: | 3073330447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2016 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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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 | 101YA0400X | C.A.P. 033 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.