Basic Information
| Provider Information | |||||||||
| NPI: | 1578020152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUMAN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | LPC, LAC, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4856 INNOVATION DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805255540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1217 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2019 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ACD.0001260 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC.0015008 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.