Healthcare Provider Details

I. General information

NPI: 1053771287
Provider Name (Legal Business Name): LA FAMILIA COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E BROADWAY AVE STE B-13
JACKSON WY
83001-8632
US

IV. Provider business mailing address

825 HI COUNTRY DR
JACKSON WY
83001-9442
US

V. Phone/Fax

Practice location:
  • Phone: 307-413-6528
  • Fax:
Mailing address:
  • Phone: 307-413-6528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1071
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number136
License Number StateWY

VIII. Authorized Official

Name: DANIELA FRANCISCA PETERSON
Title or Position: OWNER
Credential: LPC
Phone: 307-413-6528