Healthcare Provider Details

I. General information

NPI: 1881329555
Provider Name (Legal Business Name): ANDREW JOSHUA COULTER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N GURLEY AVE
GILLETTE WY
82716-2109
US

IV. Provider business mailing address

905 N GURLEY AVE
GILLETTE WY
82716-2109
US

V. Phone/Fax

Practice location:
  • Phone: 307-686-0669
  • Fax:
Mailing address:
  • Phone: 307-686-0669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPCSW-1040
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: