Provider Demographics
NPI:1962932160
Name:TATEM, ANGELE (BCABA)
Entity type:Individual
Prefix:
First Name:ANGELE
Middle Name:
Last Name:TATEM
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80437-0548
Mailing Address - Country:US
Mailing Address - Phone:303-907-1449
Mailing Address - Fax:
Practice Address - Street 1:29374 GREENWOOD LN
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7404
Practice Address - Country:US
Practice Address - Phone:303-907-1449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0-11-4361106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-11-4361OtherBOARD CERTIFICATION FOR BEHAVIOR ANALYSIS