Provider Demographics
NPI:1346564655
Name:RALEY, KRYSTAL MARIE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MARIE
Last Name:RALEY
Suffix:
Gender:F
Credentials:MA, LPC
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 7083
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-7002
Mailing Address - Country:US
Mailing Address - Phone:307-751-3769
Mailing Address - Fax:
Practice Address - Street 1:919 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5806
Practice Address - Country:US
Practice Address - Phone:307-751-3769
Practice Address - Fax:307-763-4440
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1076101YP2500X, 101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)