Provider Demographics
NPI:1518954643
Name:WILLSON, BRYCE CRAIG (MA, CACIII, LPC)
Entity Type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:CRAIG
Last Name:WILLSON
Suffix:
Gender:M
Credentials:MA, CACIII, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 ROBB ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2184
Mailing Address - Country:US
Mailing Address - Phone:303-278-7418
Mailing Address - Fax:303-223-9315
Practice Address - Street 1:3575 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3807
Practice Address - Country:US
Practice Address - Phone:303-789-2265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5782101YA0400X
CO2955101YM0800X
CO3874103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3874OtherPROFESSIONAL LICENSE
CO11638726OtherCAQH