Basic Information
| Provider Information | |||||||||
| NPI: | 1689074833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSON | ||||||||
| FirstName: | TREVOR | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2476 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820032476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076380300 | ||||||||
| FaxNumber: | 3076380394 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 E GRAND AVE UNIT 5 | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820703604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162177239 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2014 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-1699 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.