MEDICARE: ROBERT BRAGG LAT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LAT-202	WY

General Provider Information

NPI Number	:	1225469661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT BRAGG LAT

Provider Business Mailing Address
First Line	:	PO BOX 11390
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83002-1390
Country	:	US
Telephone Number	:	307-733-3908
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 W BROADWAY AVE STE L1
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8213
Country	:	US
Telephone Number	:	307-733-3908
Fax Number	:	307-734-0017

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

Provider Enumeration Date	:	12/11/2013
Last Update Date	:	12/11/2013

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