Basic Information
| Provider Information | |||||||||
| NPI: | 1851799449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENNER | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1841 MADORA AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826333057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582846 | ||||||||
| FaxNumber: | 3073581144 | ||||||||
| Practice Location | |||||||||
| Address1: | 1841 MADORA AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582846 | ||||||||
| FaxNumber: | 3073581144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2014 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | PPC-950 | WY | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | LPC-1667 | WY | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | LPC-1667 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 106402908 | 05 | WY | MEDICAID | 106402907 | 05 | WY | MEDICAID |