Provider Demographics
NPI:1306103627
Name:BAZACOS, THERESA BARBARA (PHD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:BARBARA
Last Name:BAZACOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:THERESA
Other - Middle Name:BARBARA
Other - Last Name:GATCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5221 BOWERSOX PKWY
Mailing Address - Street 2:
Mailing Address - City:FIRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5904
Mailing Address - Country:US
Mailing Address - Phone:559-618-0159
Mailing Address - Fax:
Practice Address - Street 1:5221 BOWERSOX PKWY
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504-5904
Practice Address - Country:US
Practice Address - Phone:559-618-0159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY 3724103TC0700X
FLPY8481103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical