Provider Demographics
NPI:1154491645
Name:RICHARD, MARY K (MA LPC LAT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:RICHARD
Suffix:
Gender:F
Credentials:MA LPC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5256
Mailing Address - Country:US
Mailing Address - Phone:307-634-6433
Mailing Address - Fax:307-635-7982
Practice Address - Street 1:2310 E 8TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5256
Practice Address - Country:US
Practice Address - Phone:307-634-6433
Practice Address - Fax:307-635-7982
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY182101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)