MEDICARE: PROSPERA HEALTHCARE WYOMING 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1215671185
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSPERA HEALTHCARE WYOMING LLC

Provider Business Mailing Address
First Line	:	312 W 2ND ST # 2037
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2412
Country	:	US
Telephone Number	:	972-900-2488
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 W 2ND ST # 2037
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2412
Country	:	US
Telephone Number	:	972-900-2488
Fax Number	:	972-600-2835

Authorized Official
Title or Position	:	CEO
Name	:	CHRIS TILLOTSON
Credential	:
Telephone Number	:	972-900-2488

Provider Enumeration Date	:	04/26/2022
Last Update Date	:	04/26/2022

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