Healthcare Provider Details

I. General information

NPI: 1619365533
Provider Name (Legal Business Name): MICHELLE BROBERG II MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12055 WEST 2ND PLAZA
LAKEWOOD CO
80228
US

IV. Provider business mailing address

3805 W. 26TH AVE
DENVER CO
80211
US

V. Phone/Fax

Practice location:
  • Phone: 303-425-0300
  • Fax:
Mailing address:
  • Phone: 720-878-2923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License NumberB6J5Y9K5
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: