Provider Demographics
NPI:1003048497
Name:KISH, BROOKE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:KISH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30424 UPPER BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7715
Mailing Address - Country:US
Mailing Address - Phone:303-349-2691
Mailing Address - Fax:
Practice Address - Street 1:9397 CROWN CREST BLVD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-8575
Practice Address - Country:US
Practice Address - Phone:303-349-2691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3319103TC2200X
CO0380805103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool