Provider Demographics
NPI:1861625402
Name:CRETAL, CURTIS E (MAC)
Entity type:Individual
Prefix:MR
First Name:CURTIS
Middle Name:E
Last Name:CRETAL
Suffix:
Gender:M
Credentials:MAC
Other - Prefix:MR
Other - First Name:CURTIS
Other - Middle Name:E
Other - Last Name:CRETAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MAC
Mailing Address - Street 1:PO BOX 7482
Mailing Address - Street 2:140 E BROADWAY STE #25
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-7482
Mailing Address - Country:US
Mailing Address - Phone:307-732-4199
Mailing Address - Fax:866-982-9040
Practice Address - Street 1:140 E BROADWAY
Practice Address - Street 2:STE #25
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002-7482
Practice Address - Country:US
Practice Address - Phone:307-732-4199
Practice Address - Fax:866-982-9040
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-204101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)