Healthcare Provider Details

I. General information

NPI: 1831131291
Provider Name (Legal Business Name): LAURENCE WILLIAM MELKA MSW ACSW LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 E PERSHING BLVD
CHEYENNE WY
82001-5356
US

IV. Provider business mailing address

2360 E PERSHING BLVD
CHEYENNE WY
82001-5356
US

V. Phone/Fax

Practice location:
  • Phone: 307-778-7353
  • Fax: 307-778-7512
Mailing address:
  • Phone: 307-778-7353
  • Fax: 307-778-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-099
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: