Provider Demographics
NPI:1902532096
Name:BASTUCK, RICHARD THOMAS (BS, CAS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:BASTUCK
Suffix:
Gender:M
Credentials:BS, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7215 W 46TH PL
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-3401
Mailing Address - Country:US
Mailing Address - Phone:914-400-6993
Mailing Address - Fax:
Practice Address - Street 1:7215 W 46TH PL
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-3401
Practice Address - Country:US
Practice Address - Phone:720-961-3511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0998499101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COACC.0998499OtherDORA
CO0733486274OtherHPSO