Healthcare Provider Details

I. General information

NPI: 1902340326
Provider Name (Legal Business Name): MOURNING GLORY COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E A ST STE 201
CASPER WY
82601-2252
US

IV. Provider business mailing address

1300 E A ST STE 201
CASPER WY
82601-2252
US

V. Phone/Fax

Practice location:
  • Phone: 307-235-3333
  • Fax: 307-266-5155
Mailing address:
  • Phone: 307-235-3333
  • Fax: 307-266-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number456
License Number StateWY

VIII. Authorized Official

Name: MRS. TISA M SUCHER
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 307-235-3333