Provider Demographics
NPI:1558722116
Name:TELLEZ, SEBASTIAN
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 17TH ST STE 146
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1508
Mailing Address - Country:US
Mailing Address - Phone:303-997-0305
Mailing Address - Fax:720-746-4998
Practice Address - Street 1:1312 17TH ST STE 146
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-1508
Practice Address - Country:US
Practice Address - Phone:303-997-0305
Practice Address - Fax:720-746-4998
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLRBT-17-38021106S00000X
CO351041103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000145075Medicaid