Healthcare Provider Details

I. General information

NPI: 1023526225
Provider Name (Legal Business Name): NIKKI MARIE ROSSETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 02/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 E GRAND AVE STE 506
LARAMIE WY
82070-4383
US

IV. Provider business mailing address

1003 E CANBY ST
LARAMIE WY
82072-2703
US

V. Phone/Fax

Practice location:
  • Phone: 307-399-8863
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1761
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: