Provider Demographics
NPI:1205529336
Name:BANECK BAHL, ALISA NICHOLE
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:NICHOLE
Last Name:BANECK BAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 E 94TH PL
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-3311
Mailing Address - Country:US
Mailing Address - Phone:720-272-9153
Mailing Address - Fax:
Practice Address - Street 1:4425 E 94TH PL
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-3311
Practice Address - Country:US
Practice Address - Phone:720-272-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor