Healthcare Provider Details

I. General information

NPI: 1033484118
Provider Name (Legal Business Name): LIVING WELL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S WISCONSIN AVE.
CASPER WY
82609-2936
US

IV. Provider business mailing address

PO BOX 552
CASPER WY
82602-0552
US

V. Phone/Fax

Practice location:
  • Phone: 307-472-5433
  • Fax: 307-337-3705
Mailing address:
  • Phone: 307-797-4683
  • Fax: 307-337-3705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC817
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAT286
License Number StateWY

VIII. Authorized Official

Name: MRS. COREY WENTZ
Title or Position: COUNSELOR
Credential: MS LPC LAT
Phone: 307-235-3333