Provider Information for 1841541679
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DAVID DEMOREST LPC(wyoming 1288)
Sex: Male
NPI: 1841541679
Last Updated: 2012-12-19
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1841541679 | ||||||||
| Enumeration Date | 2012-09-19 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | P.O BOX 11390 610 W BROADWAY, JACKSON, WY 83002 United States Phone: 307-734-0017 | Fax:307-200-0290 | ||||||||
| Primary Practice Address | 7520 PORCUPINE CREEK RD JACKSON, WY 83001 United States Phone: 307-259-1865 | Fax:307-200-0290 | ||||||||
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