Provider Demographics
NPI:1821384884
Name:FLETCHER, KIM E
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:E
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 ROAD 6RT
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-8873
Mailing Address - Country:US
Mailing Address - Phone:307-899-2182
Mailing Address - Fax:307-527-4210
Practice Address - Street 1:1106 JULIE LN
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-1632
Practice Address - Country:US
Practice Address - Phone:307-271-7460
Practice Address - Fax:307-271-7460
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCAPA-025101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)