MEDICARE: CASARA TATE

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	172V00000X	Community Health Worker
2	101YM0800X	Mental Health Counselor	PPC-1389	WY

General Provider Information

NPI Number	:	1013583871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASARA TATE

Provider Business Mailing Address
First Line	:	4025 RAWLINS ST
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-1900
Country	:	US
Telephone Number	:	307-426-4797
Fax Number	:

Provider Business Practice Location Address
First Line	:	427 S 21ST ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-4323
Country	:	US
Telephone Number	:	307-459-3670
Fax Number	:

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

Provider Enumeration Date	:	06/02/2021
Last Update Date	:	06/05/2023

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Directions to “ CASARA TATE ” Practice Location

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