Basic Information
| Provider Information | |||||||||
| NPI: | 1619218708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | AVIS | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820012760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074264728 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2526 SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076349653 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LPC-1448 | WY | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | LAT-332 | WY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC-796 | WY | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | LPC-796 | WY | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | LAT-332 | 01 | WY | STATE LICENSE | OTHER | LPC-796 | 01 | WY | STATE LICENSE | OTHER |