Healthcare Provider Details

I. General information

NPI: 1356268049
Provider Name (Legal Business Name): LEZLY DIAZ MORILLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W PEARL AVE
JACKSON WY
83001-8409
US

IV. Provider business mailing address

PO BOX 7899
JACKSON WY
83002-7899
US

V. Phone/Fax

Practice location:
  • Phone: 307-734-6040
  • Fax: 307-460-7343
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: