Provider Demographics
NPI:1215928965
Name:FAULKNER, KIM KNOX (PHD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:KNOX
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 PINE ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-2332
Mailing Address - Country:US
Mailing Address - Phone:307-684-5828
Mailing Address - Fax:307-684-5803
Practice Address - Street 1:135 PINE STREET
Practice Address - Street 2:SUITE B
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-2332
Practice Address - Country:US
Practice Address - Phone:307-684-5828
Practice Address - Fax:307-684-5803
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY223103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119212400Medicaid