=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699001255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETHAN LINNELL BRATT MS, LMFT, CST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2009
-----------------------------------------------------
Last Update Date | 12/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1711 61ST AVE STE 206
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80634-3049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-599-1820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1224 102ND AVE
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80634-9058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-599-1820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 0001102
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------