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General NPI Number Information
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NPI Number | 1588067037
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Entity Type | Organization
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Legal Business Name | WYOMING WELLNESS LLP
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Dates
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Enumeration Date | 09/29/2014
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Last Update Date | 09/29/2014
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Provider Practice Location Address
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Address Line | 112 E. BRIDGE SUITE G
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City | SARATOGA
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State | WY
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Zip | 82331
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Country | US
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Telephone | 307-631-4912
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Fax |
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Provider Business Mailing Address
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Address Line | 518 MONTCLAIR DR
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City | CHEYENNE
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State | WY
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Zip | 82009-2717
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Country | US
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Telephone | 307-631-4912
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Fax |
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Authorized Official
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Title or Position | GENERAL PARTNER
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Name | CHARLES E JUNKIN
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Credential | MA, LPC
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Telephone | 307-631-4912
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1122
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License Number State | WY
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