MEDICARE: LIVING WELL PC

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	251S00000X	Community/Behavioral Health Agency
2	103TC0700X	Clinical Psychologist	465	WY
3	1041C0700X	Clinical Social Worker	603	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326342023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING WELL PC

Provider Business Mailing Address
First Line	:	2510 E 15TH ST
Second Line	:	SUITE 11
City	:	CASPER
State	:	WY
Zip	:	82609-4111
Country	:	US
Telephone Number	:	307-234-9979
Fax Number	:	307-234-9989

Provider Business Practice Location Address
First Line	:	2510 E 15TH ST
Second Line	:	SUITE 11
City	:	CASPER
State	:	WY
Zip	:	82609-4111
Country	:	US
Telephone Number	:	307-234-9979
Fax Number	:	307-234-9989

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TRICIA R MILLER
Credential	:	MSW
Telephone Number	:	307-234-9979

Provider Enumeration Date	:	01/10/2011
Last Update Date	:	05/01/2015

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Directions to “LIVING WELL PC ” Practice Location

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