Healthcare Provider Details

I. General information

NPI: 1508016023
Provider Name (Legal Business Name): LAURA KIETELL MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AIRPORT PKWY STE 210B
CHEYENNE WY
82001-1541
US

IV. Provider business mailing address

1401 AIRPORT PKWY STE 210B
CHEYENNE WY
82001-1541
US

V. Phone/Fax

Practice location:
  • Phone: 307-240-2703
  • Fax: 307-222-0279
Mailing address:
  • Phone: 307-240-2703
  • Fax: 307-222-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number575
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: