Provider Demographics
NPI:1326422759
Name:BROADVISTAS PSYCHOLOGY LLC
Entity Type:Organization
Organization Name:BROADVISTAS PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADHURST
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:720-838-8141
Mailing Address - Street 1:1 KALISA WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3508
Mailing Address - Country:US
Mailing Address - Phone:888-948-6789
Mailing Address - Fax:877-345-3501
Practice Address - Street 1:5555 S ELATI ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-1624
Practice Address - Country:US
Practice Address - Phone:888-948-6789
Practice Address - Fax:877-345-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004234103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPSY.0004234OtherPROFESSIONAL LICENSE