Basic Information
| Provider Information | |||||||||
| NPI: | 1962592253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC, CAC III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32849 COUNTY ROAD 10 | ||||||||
| Address2: | |||||||||
| City: | MANZANOLA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810589711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7199800133 | ||||||||
| FaxNumber: | 7194625716 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810501329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193848503 | ||||||||
| FaxNumber: | 7193848411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3846 | CO | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 1562 | CO | X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.