MEDICARE: TRISTAN THOMAS SANDOVAL-JOHNSON MSW, PCSW

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	1041C0700X	Clinical Social Worker	PCSW-1290	WY
2	171M00000X	Case Manager/Care Coordinator		WY

General Provider Information

NPI Number	:	1801689054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRISTAN THOMAS SANDOVAL-JOHNSON MSW, PCSW

Provider Business Mailing Address
First Line	:	1263 N 15TH ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82072-2343
Country	:	US
Telephone Number	:	307-745-8915
Fax Number	:

Provider Business Practice Location Address
First Line	:	1263 N 15TH ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82072-2343
Country	:	US
Telephone Number	:	307-745-8915
Fax Number	:

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

Provider Enumeration Date	:	05/28/2025
Last Update Date	:	03/19/2026

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