Provider Demographics
NPI:1366878977
Name:ADONAI MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:ADONAI MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MHNP
Authorized Official - Phone:307-685-8255
Mailing Address - Street 1:707 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4108
Mailing Address - Country:US
Mailing Address - Phone:307-685-8255
Mailing Address - Fax:888-852-8319
Practice Address - Street 1:707 W 8TH ST
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4108
Practice Address - Country:US
Practice Address - Phone:307-685-8255
Practice Address - Fax:888-852-8319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY29650.1122261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health