Healthcare Provider Details

I. General information

NPI: 1881010379
Provider Name (Legal Business Name): PHILLIP LUKALU M.A.E. LPC-1511
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2014
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 MAIN ST
TORRINGTON WY
82240-3340
US

IV. Provider business mailing address

1419 MAIN ST
TORRINGTON WY
82240-3340
US

V. Phone/Fax

Practice location:
  • Phone: 307-532-4197
  • Fax: 307-532-8405
Mailing address:
  • Phone: 307-532-4197
  • Fax: 307-532-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1511
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: