=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306261102
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLIE HOLLINGSWORTH M.A,, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2014
-----------------------------------------------------
Last Update Date | 04/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 STAMPEDE AVE STE 201
-----------------------------------------------------
City | CODY
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82414-4818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-250-8761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2419 INA AVE
-----------------------------------------------------
City | CODY
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82414-9756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-250-8761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT-202
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------