Healthcare Provider Details

I. General information

NPI: 1760270706
Provider Name (Legal Business Name): BRAD'S HOUSE PUEBLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 BROADWAY AVE
PUEBLO CO
81004-2128
US

IV. Provider business mailing address

14960 WOODCARVER RD # 201
COLORADO SPRINGS CO
80921-2370
US

V. Phone/Fax

Practice location:
  • Phone: 719-308-1213
  • Fax:
Mailing address:
  • Phone: 719-308-1213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: PATRICK HAGGARD
Title or Position: BILLING DIRECTOR
Credential:
Phone: 719-308-1213