Healthcare Provider Details

I. General information

NPI: 1255503074
Provider Name (Legal Business Name): FAMILY DYNAMICS COUNSELING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 DEWAR DR
ROCK SPRINGS WY
82901-6218
US

IV. Provider business mailing address

4000 DEWAR DR
ROCK SPRINGS WY
82901-6218
US

V. Phone/Fax

Practice location:
  • Phone: 307-382-3010
  • Fax: 307-382-6881
Mailing address:
  • Phone: 307-382-3010
  • Fax: 307-382-6881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. JILL A JOHNSON
Title or Position: PRESIDENT
Credential: MS LMFT
Phone: 307-382-3010