Provider Demographics
NPI:1255992939
Name:TARDIBUONO, KEITH A
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:TARDIBUONO
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:PO BOX 76510
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80970-6510
Mailing Address - Country:US
Mailing Address - Phone:719-638-8844
Mailing Address - Fax:719-638-8115
Practice Address - Street 1:1322 N ACADEMY BLVD STE 204
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-3320
Practice Address - Country:US
Practice Address - Phone:719-638-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst