Healthcare Provider Details

I. General information

NPI: 1215928965
Provider Name (Legal Business Name): KIM KNOX FAULKNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 01/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PINE STREET SUITE B
BUFFALO WY
82834-2332
US

IV. Provider business mailing address

175 PINE ST
BUFFALO WY
82834-2332
US

V. Phone/Fax

Practice location:
  • Phone: 307-684-5828
  • Fax: 307-684-5803
Mailing address:
  • Phone: 307-684-5828
  • Fax: 307-684-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number223
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: