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General NPI Number Information
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NPI Number | 1558939678
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Entity Type | Individual
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Provider Name | MATTHEW AIAH GROVENSTEIN
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Gender | Male
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Dates
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Enumeration Date | 06/15/2021
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 1949 SUGARLAND DR
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City | SHERIDAN
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State | WY
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Zip | 82801-5755
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Country | US
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Telephone | 307-429-2356
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Fax |
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Provider Business Mailing Address
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Address Line | 1949 SUGARLAND DR
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City | SHERIDAN
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State | WY
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Zip | 82801-5755
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Country | US
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Telephone | 307-429-2356
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC-2146
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License Number State | WY
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