Provider Demographics
NPI:1235791286
Name:DIGITAL MEDIA TREATMENT AND EDUCATION CENTER, LLC
Entity Type:Organization
Organization Name:DIGITAL MEDIA TREATMENT AND EDUCATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CO-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:303-632-8883
Mailing Address - Street 1:2299 PEARL ST STE 310
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-4671
Mailing Address - Country:US
Mailing Address - Phone:303-635-6753
Mailing Address - Fax:303-593-1058
Practice Address - Street 1:2299 PEARL ST STE 310
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-4671
Practice Address - Country:US
Practice Address - Phone:303-635-6753
Practice Address - Fax:303-593-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-30
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1639234545Medicaid
CO1326345216Medicaid