Healthcare Provider Details

I. General information

NPI: 1952468043
Provider Name (Legal Business Name): PHILLIP KENT RECTOR PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLACK COAL DRIVE BUILDING 29
FORT WASHAKIE WY
82514
US

IV. Provider business mailing address

PO BOX 128
FORT WASHAKIE WY
82514-0128
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-7300
  • Fax: 307-332-2949
Mailing address:
  • Phone: 307-332-7300
  • Fax: 307-332-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number334
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: