MEDICARE: DAVID DEMOREST LPC(WYOMING 1288)

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPC 1288	WY

General Provider Information

NPI Number	:	1841541679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID DEMOREST LPC(WYOMING 1288)

Provider Business Mailing Address
First Line	:	P.O BOX 11390
Second Line	:	610 W BROADWAY,
City	:	JACKSON
State	:	WY
Zip	:	83002
Country	:	US
Telephone Number	:	307-734-0017
Fax Number	:	307-200-0290

Provider Business Practice Location Address
First Line	:	7520 PORCUPINE CREEK RD
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001
Country	:	US
Telephone Number	:	307-259-1865
Fax Number	:	307-200-0290

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2012
Last Update Date	:	12/19/2012

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