Basic Information
| Provider Information | |||||||||
| NPI: | 1902863996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDSOCG | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, NCC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2417 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820032417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076380300 | ||||||||
| FaxNumber: | 3076380394 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W 17TH ST | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076375808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LPC-166 LAT-142 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 311832 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER |