Basic Information
| Provider Information | |||||||||
| NPI: | 1740613306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ-CODALLOS | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820012760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074264728 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1263 N 15TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458915 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2013 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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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 | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.