Provider Demographics
NPI:1306454764
Name:RASMUSSEN, SHONDRA M
Entity type:Individual
Prefix:
First Name:SHONDRA
Middle Name:M
Last Name:RASMUSSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SUNSET DR SPC 30
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-6902
Mailing Address - Country:US
Mailing Address - Phone:307-679-1969
Mailing Address - Fax:
Practice Address - Street 1:3800 SUNSET DR SPC 30
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-6902
Practice Address - Country:US
Practice Address - Phone:307-679-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WYRBT-20-148355106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYRBT-20-148355OtherBACB