MEDICARE: MARISSA WIDIKER

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	101Y00000X	Counselor	PPC-1619	WY

General Provider Information

NPI Number	:	1639037211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA WIDIKER

Provider Business Mailing Address
First Line	:	PO BOX 34
Second Line	:
City	:	GLENROCK
State	:	WY
Zip	:	82637-0034
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 E 1ST ST STE A
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2753
Country	:	US
Telephone Number	:	307-234-9979
Fax Number	:

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

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/22/2026

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Directions to “ MARISSA WIDIKER ” Practice Location

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