Healthcare Provider Details

I. General information

NPI: 1144135690
Provider Name (Legal Business Name): ELIZABETH PERRY PPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E BROADWAY AVE # B13
JACKSON WY
83001-8632
US

IV. Provider business mailing address

PO BOX 535
VICTOR ID
83455-0535
US

V. Phone/Fax

Practice location:
  • Phone: 307-203-5002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPPC-1696
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: