Healthcare Provider Details

I. General information

NPI: 1427517507
Provider Name (Legal Business Name): GYPSY PETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 BLUEBELL LN
CUSTER SD
57730-2455
US

IV. Provider business mailing address

1218 BLUEBELL LN
CUSTER SD
57730-2455
US

V. Phone/Fax

Practice location:
  • Phone: 605-920-1032
  • Fax:
Mailing address:
  • Phone: 605-920-1032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1464
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC20921
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: