Healthcare Provider Details

I. General information

NPI: 1801417910
Provider Name (Legal Business Name): BRADLEY WIETHARN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 W JEFFERSON AVE
LAKEWOOD CO
80235-2031
US

IV. Provider business mailing address

13955 FOX HOLLOW CT
BROOMFIELD CO
80020-6199
US

V. Phone/Fax

Practice location:
  • Phone: 303-225-7673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: