=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184006876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | H.O.P.E. COUNSELING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2015
-----------------------------------------------------
Last Update Date | 06/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 S GILLETTE AVE 216
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-689-9090
-----------------------------------------------------
Fax | 307-689-9090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 227
-----------------------------------------------------
City | ROZET
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82727-0227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-689-9090
-----------------------------------------------------
Fax | 307-689-9090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | KELLEY M BOLTIN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 307-689-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 1475
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------