Healthcare Provider Details

I. General information

NPI: 1982938114
Provider Name (Legal Business Name): STEPHANIE M KETTL MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 W PERSHING BLVD
CHEYENNE WY
82001-2537
US

IV. Provider business mailing address

821 W PERSHING BLVD
CHEYENNE WY
82001-2537
US

V. Phone/Fax

Practice location:
  • Phone: 307-421-9329
  • Fax: 307-635-3965
Mailing address:
  • Phone: 307-421-9329
  • Fax: 307-635-3965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1017
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1017
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: