MEDICARE: TRYSTA N WEDDING LPCC

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	101YM0800X	Mental Health Counselor	LPCC.0020333	CO

General Provider Information

NPI Number	:	1619680279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRYSTA N WEDDING LPCC

Provider Business Mailing Address
First Line	:	30049 LIGHTENING LN
Second Line	:
City	:	EVERGREEN
State	:	CO
Zip	:	80439-8748
Country	:	US
Telephone Number	:	720-480-2689
Fax Number	:

Provider Business Practice Location Address
First Line	:	3470 S SHERMAN ST STE 2
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80113-2663
Country	:	US
Telephone Number	:	720-443-1373
Fax Number	:

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

Provider Enumeration Date	:	12/28/2022
Last Update Date	:	12/28/2022

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