Provider Demographics
NPI:1033695804
Name:STUFFLEBEAM, LORRY (LCSW)
Entity Type:Individual
Prefix:
First Name:LORRY
Middle Name:
Last Name:STUFFLEBEAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1474
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-1474
Mailing Address - Country:US
Mailing Address - Phone:307-522-1541
Mailing Address - Fax:
Practice Address - Street 1:70 3RD AVE
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-8311
Practice Address - Country:US
Practice Address - Phone:307-522-1541
Practice Address - Fax:307-459-6800
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1033695804OtherBLUE CROSS BLUE SHIELD OF WYOMING