Active NPI
Suzanne Petren
- Clinical Psychologist
- Evanston, WY
National Provider Identifier
1356486245
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 424
- Practice address
- 50 Allegiance Cir
Evanston, WY 82930-3804 - Phone
- (307) 789-3710
- Fax
- (307) 789-0823
- NPI assigned
- Feb 20, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 424 | WY | Primary |
Addresses
Primary practice location
50 Allegiance Cir
Evanston, WY 82930-3804
Mailing address
PO Box 6005
Evanston, WY 82931-6005
Phone (307) 789-3710
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 121776300 | Medicaid | WY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 424 | WY | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1171929600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1399507200000",
"number": "1356486245",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 6005",
"city": "EVANSTON",
"state": "WY",
"postal_code": "829316005",
"telephone_number": "307-789-3710",
"fax_number": "307-789-0823"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "50 ALLEGIANCE CIR",
"city": "EVANSTON",
"state": "WY",
"postal_code": "829303804",
"telephone_number": "307-789-3710",
"fax_number": "307-789-0823"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETREN",
"first_name": "SUZANNE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-02-20",
"last_updated": "2014-05-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "WY",
"license": "424",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "121776300",
"state": "WY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Evanston, WY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 8, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.