Healthcare Provider Details

I. General information

NPI: 1174451876
Provider Name (Legal Business Name): EXPANSIVE SELF PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915A 11TH ST
GOLDEN CO
80401-1105
US

IV. Provider business mailing address

619 12TH ST # 523
GOLDEN CO
80401-1108
US

V. Phone/Fax

Practice location:
  • Phone: 720-575-0977
  • Fax:
Mailing address:
  • Phone: 720-575-0977
  • Fax: 720-815-0258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CAMILLE BRUNEL
Title or Position: OWNER, THERAPIST
Credential: LPC
Phone: 720-575-0977