Healthcare Provider Details

I. General information

NPI: 1356651137
Provider Name (Legal Business Name): LISA KJERSTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7391 RIMROCK DR
GILLETTE WY
82718-7162
US

IV. Provider business mailing address

7391 RIMROCK DR
GILLETTE WY
82718-7162
US

V. Phone/Fax

Practice location:
  • Phone: 307-685-4363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-684
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: