MEDICARE: DIANE BARTKO MA, LPC, BC-DMT

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	101YP2500X	Professional Counselor	LPC1401	CO

General Provider Information

NPI Number	:	1659106235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE BARTKO MA, LPC, BC-DMT

Provider Business Mailing Address
First Line	:	2415 GRAPE AVE
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80304-2831
Country	:	US
Telephone Number	:	303-941-1069
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 POPLAR AVE STE 735
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80304-1067
Country	:	US
Telephone Number	:	303-941-1069
Fax Number	:

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

Provider Enumeration Date	:	09/04/2024
Last Update Date	:	09/04/2024

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