Healthcare Provider Details

I. General information

NPI: 1053894253
Provider Name (Legal Business Name): JEFF STONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E MADISON AVE STE 1
RIVERTON WY
82501-4712
US

IV. Provider business mailing address

625 E. MADISON STREET SUITE 1
LANDER WY
82520
US

V. Phone/Fax

Practice location:
  • Phone: 307-463-0337
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1134
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: