Provider Demographics
NPI:1194226266
Name:HIGH DESERT PSYCHOLOGY AND WELLNESS
Entity type:Organization
Organization Name:HIGH DESERT PSYCHOLOGY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:435-631-9918
Mailing Address - Street 1:235 HAYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5606
Mailing Address - Country:US
Mailing Address - Phone:435-631-9918
Mailing Address - Fax:
Practice Address - Street 1:191 OVERTHRUST RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9261
Practice Address - Country:US
Practice Address - Phone:435-631-9918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY306261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)