Basic Information
| Provider Information | |||||||||
| NPI: | 1861624678 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMARY MENTAL HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 THELMA DR | ||||||||
| Address2: | PMB #464 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072593467 | ||||||||
| FaxNumber: | 3072665155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 WILKINGS CIRCLE | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826011336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072359583 | ||||||||
| FaxNumber: | 3072657277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2009 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | DECASTRO | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3072593467 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | APRN-BC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 18154.0972 | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.