Provider Demographics
NPI:1962167098
Name:PFANKUCH, ALYSE (MA)
Entity type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:PFANKUCH
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:
Other - Last Name:MCSHANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4726 MOUNTAIN RD APT 520
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-5157
Mailing Address - Country:US
Mailing Address - Phone:307-221-0317
Mailing Address - Fax:
Practice Address - Street 1:1918 THOMES AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3527
Practice Address - Country:US
Practice Address - Phone:307-313-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-2270101Y00000X
IA130923101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor