Healthcare Provider Details

I. General information

NPI: 1174242572
Provider Name (Legal Business Name): BRYDEN SPEVAK LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

IV. Provider business mailing address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

V. Phone/Fax

Practice location:
  • Phone: 440-212-5508
  • Fax:
Mailing address:
  • Phone: 440-212-5508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW.0009923364
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: