Basic Information
| Provider Information | |||||||||
| NPI: | 1861577140 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLOUD PEAK COUNSELING CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WASHAKIE MENTAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S 23RD ST | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073476165 | ||||||||
| FaxNumber: | 3073476166 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S 23RD ST | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073476165 | ||||||||
| FaxNumber: | 3073476166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSSLER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3073476165 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | WY | N | Agencies | Day Training, Developmentally Disabled Services | 261QR0405X | WY | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 106352906 | 05 | WY | MEDICAID | 106352904 | 05 | WY | MEDICAID | 106352900 | 05 | WY | MEDICAID | 106352908 | 05 | WY | MEDICAID | 106352905 | 05 | WY | MEDICAID | 106352907 | 05 | WY | MEDICAID | 106352903 | 05 | WY | MEDICAID |