Basic Information
| Provider Information | |||||||||
| NPI: | 1902806383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOFFORD | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 9TH ST | ||||||||
| Address2: | |||||||||
| City: | WHEATLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 822012909 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1954 W MARIPOSA PKWY | ||||||||
| Address2: | |||||||||
| City: | WHEATLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 822013102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073223190 | ||||||||
| FaxNumber: | 3073223198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YP2500X | 741 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 313262 | 01 | WY | BS | OTHER |