Provider Demographics
NPI:1578939864
Name:JOSTAD, BROOKE TUTTLE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:TUTTLE
Last Name:JOSTAD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 RAWLINS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1900
Mailing Address - Country:US
Mailing Address - Phone:307-426-4797
Mailing Address - Fax:307-426-4799
Practice Address - Street 1:2550 STOVER ST BLDG C
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4641
Practice Address - Country:US
Practice Address - Phone:970-942-3031
Practice Address - Fax:307-426-4799
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-13591041C0700X
COCSW.099252681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000175168Medicaid