Healthcare Provider Details

I. General information

NPI: 1366981458
Provider Name (Legal Business Name): BLAISE RASTELLO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 CHERRY AVE UNIT A
BOULDER CO
80304-4329
US

IV. Provider business mailing address

951 CHERRY AVE UNIT A
BOULDER CO
80304-4329
US

V. Phone/Fax

Practice location:
  • Phone: 720-391-9951
  • Fax:
Mailing address:
  • Phone: 720-391-9951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09926473
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: