Basic Information
| Provider Information | |||||||||
| NPI: | 1861510281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL WYOMING COUNSELING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 WILKINS CIR | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826011336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072379583 | ||||||||
| FaxNumber: | 3072657277 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 WILKINS CIR | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826011336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072379583 | ||||||||
| FaxNumber: | 3072657277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAZUCHA | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3072379583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW-R | ||||||||
| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 106049008 | 05 | WY | MEDICAID |