Healthcare Provider Details

I. General information

NPI: 1679905301
Provider Name (Legal Business Name): TYRONE S BRAXTON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

777 BANNOCK ST
DENVER CO
80204-4507
US

V. Phone/Fax

Practice location:
  • Phone: 720-424-1080
  • Fax:
Mailing address:
  • Phone: 720-424-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberCSW.09924488
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09924488
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: