Healthcare Provider Details

I. General information

NPI: 1285273318
Provider Name (Legal Business Name): JUSTIN BRENT WALMSLEY LAC, MFTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 30TH ST STE 350
BOULDER CO
80301-1071
US

IV. Provider business mailing address

1790 30TH ST STE 350
BOULDER CO
80301-1071
US

V. Phone/Fax

Practice location:
  • Phone: 720-970-7752
  • Fax:
Mailing address:
  • Phone: 720-970-7752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFTC.0014400
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0002505
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: