MEDICARE: DR. TIMOTHY BRUNELLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	103G00000X	Clinical Neuropsychologist	5524	CO

General Provider Information

NPI Number	:	1225488349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY BRUNELLE

Provider Business Mailing Address
First Line	:	255 CANYON BLVD STE 200
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80302-4954
Country	:	US
Telephone Number	:	720-744-0577
Fax Number	:	720-638-3699

Provider Business Practice Location Address
First Line	:	255 CANYON BLVD STE 200
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80302-4954
Country	:	US
Telephone Number	:	720-744-0577
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2016
Last Update Date	:	01/31/2022

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Directions to “ DR. TIMOTHY BRUNELLE ” Practice Location

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