Healthcare Provider Details

I. General information

NPI: 1689902009
Provider Name (Legal Business Name): UPLIFT COUNSELING & DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W BUFFALO ST DOWNSTAIRS
RAWLINS WY
82301-5622
US

IV. Provider business mailing address

PO BOX 911
RAWLINS WY
82301-0911
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-5899
  • Fax: 307-324-2695
Mailing address:
  • Phone: 307-324-5899
  • Fax: 307-324-2695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-905
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number468
License Number StateWY

VIII. Authorized Official

Name: CHARLES JUNKIN
Title or Position: OWNER
Credential: LPC
Phone: 307-324-5899