Healthcare Provider Details

I. General information

NPI: 1700721701
Provider Name (Legal Business Name): BLUE BISON PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40047 COUNTY ROAD 31
AULT CO
80610-9721
US

IV. Provider business mailing address

4603 DUSTY SAGE CT UNIT 4
FORT COLLINS CO
80526-3753
US

V. Phone/Fax

Practice location:
  • Phone: 970-420-3778
  • Fax:
Mailing address:
  • Phone: 970-420-3756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA THATE BALDASARO
Title or Position: OWNER
Credential: PMHNP
Phone: 970-420-3756