Provider Demographics
NPI:1215310065
Name:SIMONSON, KATHARINE B
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:B
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:B
Other - Last Name:STICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1841 MADORA AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-3057
Mailing Address - Country:US
Mailing Address - Phone:307-358-2846
Mailing Address - Fax:307-358-1144
Practice Address - Street 1:1841 MADORA AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633
Practice Address - Country:US
Practice Address - Phone:307-358-2846
Practice Address - Fax:307-358-1144
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1638101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106402908Medicaid
WY106402907Medicaid