Healthcare Provider Details

I. General information

NPI: 1578784377
Provider Name (Legal Business Name): EARL H FAULKNER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ALDEN DR CHEYENNE, WY
FE WARREN AFB WY
82005-3906
US

IV. Provider business mailing address

6900 ALDEN DR CHEYENNE, WY
FE WARREN AFB WY
82005-3906
US

V. Phone/Fax

Practice location:
  • Phone: 307-773-2998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberPHD-419
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPHD-419
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPHD-419
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPHD-419
License Number StateWY
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPHD-419
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: