Healthcare Provider Details

I. General information

NPI: 1457219784
Provider Name (Legal Business Name): REBECCA THATE BALDASARO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 RIVERSIDE AVE
FORT COLLINS CO
80524-4374
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 970-888-4070
  • Fax:
Mailing address:
  • Phone: 970-420-3778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.1001737-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: