Healthcare Provider Details

I. General information

NPI: 1629831417
Provider Name (Legal Business Name): TRISTAN BENZON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 AIRPORT WAY STE 125
BROOMFIELD CO
80021-2729
US

IV. Provider business mailing address

12303 AIRPORT WAY STE 125
BROOMFIELD CO
80021-2729
US

V. Phone/Fax

Practice location:
  • Phone: 970-310-3406
  • Fax: 888-965-4615
Mailing address:
  • Phone: 970-310-3406
  • Fax: 888-965-4615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0023545
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2023036734
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20205030280
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: