MEDICARE: LA FAMILIA COUNSELING SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	136	WY
2	101YP2500X	Professional Counselor	1071	WY

General Provider Information

NPI Number	:	1053771287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA FAMILIA COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	825 HI COUNTRY DR
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-9442
Country	:	US
Telephone Number	:	307-413-6528
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 E BROADWAY AVE STE B-13
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8632
Country	:	US
Telephone Number	:	307-413-6528
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DANIELA FRANCISCA PETERSON
Credential	:	LPC
Telephone Number	:	307-413-6528

Provider Enumeration Date	:	03/01/2016
Last Update Date	:	03/01/2016

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