Basic Information
| Provider Information | |||||||||
| NPI: | 1679975635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMORY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSW, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRENDERGRAST | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | BLAKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1914 THOMES AVE | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076319931 | ||||||||
| FaxNumber: | 3076357706 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076319931 | ||||||||
| FaxNumber: | 3076357706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2014 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 235 | WY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 1725 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.