Provider Demographics
NPI:1700177300
Name:FACKRELL, BEVERLY (LPC)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:FACKRELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:BEV
Other - Middle Name:
Other - Last Name:FACKRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS LPC
Mailing Address - Street 1:190 OVERTHRUST ROAD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-4615
Mailing Address - Country:US
Mailing Address - Phone:307-679-8765
Mailing Address - Fax:
Practice Address - Street 1:177 WOODRIDGE LN
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-4615
Practice Address - Country:US
Practice Address - Phone:307-679-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC 1289101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional