Healthcare Provider Details

I. General information

NPI: 1235791286
Provider Name (Legal Business Name): DIGITAL MEDIA TREATMENT AND EDUCATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2019
Last Update Date: 06/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 PEARL ST STE 310
BOULDER CO
80302-4671
US

IV. Provider business mailing address

2299 PEARL ST STE 310
BOULDER CO
80302-4671
US

V. Phone/Fax

Practice location:
  • Phone: 303-635-6753
  • Fax: 303-593-1058
Mailing address:
  • Phone: 303-635-6753
  • Fax: 303-593-1058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name: BRETT KENNEDY
Title or Position: OWNER, CO-DIRECTOR
Credential: PSY.D.
Phone: 303-632-8883