Provider Demographics
NPI:1902612070
Name:ENRIQUEZ, IDEL
Entity type:Individual
Prefix:
First Name:IDEL
Middle Name:
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IDELFONSO
Other - Middle Name:
Other - Last Name:ENRIQUEZ CARVAJAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6930 COLUMBIA RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-5462
Mailing Address - Country:US
Mailing Address - Phone:307-462-9802
Mailing Address - Fax:
Practice Address - Street 1:420 W PEARL AVE FL 2
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8409
Practice Address - Country:US
Practice Address - Phone:307-734-6040
Practice Address - Fax:307-460-7343
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health