MEDICARE: RANDY A BRALEY PHD LMFT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3770	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3770	OTHER	CO	PROFESSIONAL LICENSE

General Provider Information

NPI Number	:	1407109010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDY A BRALEY PHD LMFT LLC

Provider Business Mailing Address
First Line	:	5310 WARD RD
Second Line	:	SUITE 106
City	:	ARVADA
State	:	CO
Zip	:	80002-1832
Country	:	US
Telephone Number	:	303-278-7418
Fax Number	:	888-341-5050

Provider Business Practice Location Address
First Line	:	2201 DOWNING ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-5234
Country	:	US
Telephone Number	:	303-278-7418
Fax Number	:	888-341-5050

Authorized Official
Title or Position	:	OWNER
Name	:	RANDY A BRALEY
Credential	:	PHD
Telephone Number	:	303-726-8754

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	10/19/2012

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