Healthcare Provider Details

I. General information

NPI: 1396833695
Provider Name (Legal Business Name): HOLISTIC COMMUNITY SERVICES-A DIFFERENT WAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 BROOKSIDE PL
DAYTON WY
82836
US

IV. Provider business mailing address

614 BROOKSIDE PL
DAYTON WY
82836
US

V. Phone/Fax

Practice location:
  • Phone: 307-655-2321
  • Fax:
Mailing address:
  • Phone: 307-655-2321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAT #292; LPC #951
License Number StateWY

VIII. Authorized Official

Name: MS. NANAYMIE KASMIRA GODFREY
Title or Position: THERAPIST/CO-DIRECTOR
Credential: LAT,MAC,LPC
Phone: 307-655-2321