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General NPI Number Information
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NPI Number | 1700721701
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Entity Type | Organization
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Legal Business Name | BLUE BISON PSYCHIATRY, LLC
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Dates
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Enumeration Date | 04/23/2026
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Last Update Date | 04/23/2026
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Provider Practice Location Address
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Address Line | 40047 COUNTY ROAD 31
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City | AULT
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State | CO
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Zip | 80610-9721
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Country | US
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Telephone | 970-420-3778
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Fax |
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Provider Business Mailing Address
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Address Line | 4603 DUSTY SAGE CT UNIT 4
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City | FORT COLLINS
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State | CO
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Zip | 80526-3753
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Country | US
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Telephone | 970-420-3756
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. REBECCA THATE BALDASARO
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Credential | PMHNP
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Telephone | 970-420-3756
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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