Provider Demographics
NPI:1659568061
Name:BANCHERO, ROBERT ALLAN (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLAN
Last Name:BANCHERO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-3506
Mailing Address - Country:US
Mailing Address - Phone:720-290-5286
Mailing Address - Fax:303-469-7375
Practice Address - Street 1:671 N GRANT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-3506
Practice Address - Country:US
Practice Address - Phone:720-290-5286
Practice Address - Fax:303-469-7375
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-29
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY-3077103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11952422OtherCAQH
CO92422764Medicaid
CO415261Medicare PIN