Provider Demographics
NPI:1104182336
Name:HUCKFELDT-MUNDT, KIMBERLY DAWN (LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:HUCKFELDT-MUNDT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:HUCKFELDT-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2802 W C ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1834
Mailing Address - Country:US
Mailing Address - Phone:307-532-0134
Mailing Address - Fax:
Practice Address - Street 1:2802 W C ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1834
Practice Address - Country:US
Practice Address - Phone:307-532-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60179545101YA0400X
WAMC60164858101YM0800X
171M00000X
WYLPC-1587101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY136831100Medicaid