MEDICARE: ALEX DIMITRIJEVIC M.A.

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	LPC-1754	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	314626	OTHER	WY	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1932273794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEX DIMITRIJEVIC M.A.

Provider Business Mailing Address
First Line	:	502 S 4TH ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-3704
Country	:	US
Telephone Number	:	307-755-1000
Fax Number	:	307-742-9717

Provider Business Practice Location Address
First Line	:	502 S 4TH ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-3704
Country	:	US
Telephone Number	:	307-755-1000
Fax Number	:	307-742-9717

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	02/21/2019

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