Healthcare Provider Details

I. General information

NPI: 1992008841
Provider Name (Legal Business Name): JUSTIN DEAN MCCOLL LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 RD 8 RA
POWELL WY
82435
US

IV. Provider business mailing address

89 RD 8 RA
POWELL WY
82435
US

V. Phone/Fax

Practice location:
  • Phone: 307-645-3384
  • Fax: 307-645-3385
Mailing address:
  • Phone: 307-645-3384
  • Fax: 307-645-3385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number957
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: