Healthcare Provider Details

I. General information

NPI: 1386825446
Provider Name (Legal Business Name): KIPP DANA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 ADAMS
AFTON WY
83110-0376
US

IV. Provider business mailing address

404 NORTH SPRAGUE CREEK RD. P.O BOX 24
FAIRVIEW WY
83119-0024
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-9883
  • Fax:
Mailing address:
  • Phone: 307-723-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAT-220
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC3048
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-550
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: