Healthcare Provider Details

I. General information

NPI: 1912251489
Provider Name (Legal Business Name): FAMILY AND PERSONAL COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 S MAIN ST
SHERIDAN WY
82801-4222
US

IV. Provider business mailing address

PO BOX 6484
SHERIDAN WY
82801-1884
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-6789
  • Fax: 307-672-6789
Mailing address:
  • Phone: 307-672-6789
  • Fax: 307-672-6789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LYNN EUVOYNNE GORDON
Title or Position: DIRECTOR
Credential: MS, LPC, NCC
Phone: 307-672-6789