Provider Demographics
NPI:1144368663
Name:TREESE, GWEN
Entity type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:
Last Name:TREESE
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 1:214 HWY 20 SO.
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443
Mailing Address - Country:US
Mailing Address - Phone:307-272-1472
Mailing Address - Fax:
Practice Address - Street 1:214 US HIGHWAY 20 S UNIT B
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-9512
Practice Address - Country:US
Practice Address - Phone:307-272-1472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child