Basic Information
| Provider Information | |||||||||
| NPI: | 1356453922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAMMI VACHA HAASE PHD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1236 E ELIZABETH ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881668 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2553 BARRY LN | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805249366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706896868 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 04/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | VACHA-HAASE | ||||||||
| AuthorizedOfficialFirstName: | TAMMI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9706896868 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | CJ8674 | 01 | CO | MEDICARE RR | OTHER | 08489521 | 05 | CO | MEDICAID |