Basic Information
| Provider Information | |||||||||
| NPI: | 1699383109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROADVISTAS PSYCHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 ROBB ST STE 201 | ||||||||
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| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889486789 | ||||||||
| FaxNumber: | 8773453501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3131 S FEDERAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802362713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889486789 | ||||||||
| FaxNumber: | 8773453501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2020 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROADHURST | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7208388141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.