Provider Demographics
NPI:1033544150
Name:INTEGRATIVE WELL-BEING
Entity Type:Organization
Organization Name:INTEGRATIVE WELL-BEING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERTILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-760-5450
Mailing Address - Street 1:1622 SHIELD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2333
Mailing Address - Country:US
Mailing Address - Phone:307-760-5450
Mailing Address - Fax:
Practice Address - Street 1:1622 SHIELD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2333
Practice Address - Country:US
Practice Address - Phone:307-760-5450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW6061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty