Basic Information
| Provider Information | |||||||||
| NPI: | 1326422759 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROADVISTAS PSYCHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 ROBB ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032787418 | ||||||||
| FaxNumber: | 3032239315 | ||||||||
| Practice Location | |||||||||
| Address1: | 2311 E BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806012547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889486789 | ||||||||
| FaxNumber: | 8773453501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2015 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | BROADHURST | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7208388141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY.0004234 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PSY.0004234 | 01 | CO | PROFESSIONAL LICENSE | OTHER |