Provider Demographics
NPI:1821501552
Name:PHIMPHASONE-BRADY, PHOUTHDAVONE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHOUTHDAVONE
Middle Name:
Last Name:PHIMPHASONE-BRADY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NOY
Other - Middle Name:
Other - Last Name:PHIMPHASONE-BRADY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13001 E 17TH PL FL 2
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2570
Practice Address - Country:US
Practice Address - Phone:303-724-1000
Practice Address - Fax:303-724-9472
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSYC.0005074103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service