Healthcare Provider Details

I. General information

NPI: 1649921784
Provider Name (Legal Business Name): ALYSSA JOANNE GONSHOROWSKI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 OVERTHRUST RD
EVANSTON WY
82930
US

IV. Provider business mailing address

1248 E 17TH ST
IDAHO FALLS ID
83404-6147
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-4224
  • Fax: 307-789-4225
Mailing address:
  • Phone: 208-542-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCP5164-R
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1943
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: