MEDICARE: COLLIN M KOSIBA PCSW-1289

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	PCSW-1289	WY

General Provider Information

NPI Number	:	1235084377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN M KOSIBA PCSW-1289

Provider Business Mailing Address
First Line	:	3207 SPARKS RD STE 200
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-6152
Country	:	US
Telephone Number	:	307-369-4710
Fax Number	:	307-222-0279

Provider Business Practice Location Address
First Line	:	3207 SPARKS RD STE 200
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-6152
Country	:	US
Telephone Number	:	307-369-4710
Fax Number	:	307-222-0279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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