Provider Demographics
NPI:1912429796
Name:BIASTOCH, MARTHA ANNE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANNE
Last Name:BIASTOCH
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7170 S WENATCHEE WAY UNIT B
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-4066
Mailing Address - Country:US
Mailing Address - Phone:303-601-3032
Mailing Address - Fax:
Practice Address - Street 1:3220 N ACADEMY BLVD STE 3
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5115
Practice Address - Country:US
Practice Address - Phone:303-601-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0106113101Y00000X
COLPC.0015354101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor