Healthcare Provider Details

I. General information

NPI: 1528239829
Provider Name (Legal Business Name): GERRY RYAN BURTON MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 E MAIN ST
LOVELL WY
82431-2001
US

IV. Provider business mailing address

PO BOX 296
LOVELL WY
82431-0296
US

V. Phone/Fax

Practice location:
  • Phone: 307-272-4972
  • Fax:
Mailing address:
  • Phone: 307-272-4972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1028
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: