Provider Demographics
NPI:1154949311
Name:BAKKE-LYSAKER, ALTHEA M (PHD)
Entity type:Individual
Prefix:DR
First Name:ALTHEA
Middle Name:M
Last Name:BAKKE-LYSAKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:RAMY
Other - Middle Name:
Other - Last Name:BAKKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:12021 PENNSYLVANIA ST STE 109A
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3151
Mailing Address - Country:US
Mailing Address - Phone:720-842-2400
Mailing Address - Fax:
Practice Address - Street 1:12021 PENNSYLVANIA ST STE 109A
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-3151
Practice Address - Country:US
Practice Address - Phone:720-842-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000273101YA0400X
CO2278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)