Provider Demographics
NPI:1063894632
Name:TETON YOUTH & FAMILY SERVICES- RED TOP MEADOWS
Entity type:Organization
Organization Name:TETON YOUTH & FAMILY SERVICES- RED TOP MEADOWS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-733-9098
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-0290
Mailing Address - Country:US
Mailing Address - Phone:307-733-9098
Mailing Address - Fax:307-733-7672
Practice Address - Street 1:7905 S. FALL CREEK ROAD
Practice Address - Street 2:BOX 290
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014-0290
Practice Address - Country:US
Practice Address - Phone:307-733-9098
Practice Address - Fax:307-733-7672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-892261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)