Healthcare Provider Details

I. General information

NPI: 1811817711
Provider Name (Legal Business Name): MR. PETER BRYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PETER EUGENE GOEDICKE

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 E 12TH AVE
DENVER CO
80220-2415
US

IV. Provider business mailing address

2655 S KING ST
DENVER CO
80219-5836
US

V. Phone/Fax

Practice location:
  • Phone: 303-525-6441
  • Fax:
Mailing address:
  • Phone: 303-525-6441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACC-0006414
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: