Healthcare Provider Details

I. General information

NPI: 1770146680
Provider Name (Legal Business Name): THADDEUS FRYE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 07/17/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 ITHACA DR
BOULDER CO
80305-6334
US

IV. Provider business mailing address

1320 ITHACA DR
BOULDER CO
80305-6334
US

V. Phone/Fax

Practice location:
  • Phone: 130-335-8950
  • Fax:
Mailing address:
  • Phone: 303-358-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.00001285
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: