MEDICARE: VIRAGO WELLNESS INITIATIVE, 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	101YP2500X	Professional Counselor
2	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1285412411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRAGO WELLNESS INITIATIVE, LLC

Provider Business Mailing Address
First Line	:	W6240 COMMUNICATION CT STE 2
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54914-8549
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	W6240 COMMUNICATION CT STE 2
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54914-8549
Country	:	US
Telephone Number	:	920-428-0580
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST/OWNER
Name	:	DR. CASEY HANSON
Credential	:
Telephone Number	:	920-428-0580

Provider Enumeration Date	:	09/19/2023
Last Update Date	:	11/15/2023

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