Provider Demographics
NPI:1578784377
Name:FAULKNER, EARL H (PHD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:H
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 1:6900 ALDEN DR
Mailing Address - Street 2:CHEYENNE, WY
Mailing Address - City:FE WARREN AFB
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:CHEYENNE, WY
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-3906
Practice Address - Country:US
Practice Address - Phone:307-773-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPHD-419101YA0400X, 101YM0800X, 103T00000X, 103TA0400X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY122963000Medicaid