Healthcare Provider Details

I. General information

NPI: 1114541406
Provider Name (Legal Business Name): BROADVISTAS PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 E LOWRY BLVD
DENVER CO
80230-6932
US

IV. Provider business mailing address

1 KALISA WAY STE 101
PARAMUS NJ
07652-3508
US

V. Phone/Fax

Practice location:
  • Phone: 888-948-6789
  • Fax: 877-345-3501
Mailing address:
  • Phone: 888-948-6789
  • Fax: 877-345-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: THOMAS JUDSON BROADHURST
Title or Position: OWNER
Credential: PSYD
Phone: 303-278-7418