Provider Demographics
NPI:1871103127
Name:LUPINE MENTAL HEALTH AND INTEGRATIVE PSYCHIATRY LLC
Entity type:Organization
Organization Name:LUPINE MENTAL HEALTH AND INTEGRATIVE PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:307-203-2656
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 E PEARL AVE STE 207
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8599
Practice Address - Country:US
Practice Address - Phone:307-203-2656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)