Provider Demographics
NPI:1225488349
Name:BRUNELLE, TIMOTHY
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:BRUNELLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 CANYON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-4954
Mailing Address - Country:US
Mailing Address - Phone:720-744-0577
Mailing Address - Fax:720-638-3699
Practice Address - Street 1:255 CANYON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-4954
Practice Address - Country:US
Practice Address - Phone:720-744-0577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CO5524103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health