Basic Information
| Provider Information | |||||||||
| NPI: | 1841364320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | TRISTIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1263 N 15TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820722343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458915 | ||||||||
| FaxNumber: | 3077458761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1263 N 15TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820722343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077458915 | ||||||||
| FaxNumber: | 3077458761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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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 | 101Y00000X | 1012 | WY | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 315841 | 01 | WY | BLUE SHIELD | OTHER |