MEDICARE: TBT, LLC

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	251S00000X	Community/Behavioral Health Agency	LCSW-837	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407230766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TBT, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2299
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-2299
Country	:	US
Telephone Number	:	307-734-6040
Fax Number	:	307-734-6040

Provider Business Practice Location Address
First Line	:	480 S CACHE ST
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8222
Country	:	US
Telephone Number	:	307-734-6040
Fax Number	:	307-734-6040

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER BRADOF
Credential	:	LCSW
Telephone Number	:	307-734-6040

Provider Enumeration Date	:	07/16/2015
Last Update Date	:	07/16/2015

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