Provider Demographics
NPI:1538898358
Name:WAHLERT, BROCK
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:WAHLERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3239
Mailing Address - Country:US
Mailing Address - Phone:307-463-0462
Mailing Address - Fax:307-856-6459
Practice Address - Street 1:603 E CARLSON ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4443
Practice Address - Country:US
Practice Address - Phone:307-514-9999
Practice Address - Fax:307-514-6006
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1719225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYOT-1719OtherSTATE LICENSE