Provider Demographics
NPI:1649801465
Name:BROEILS, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BROEILS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 TREMONT ST APT A2
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6053
Mailing Address - Country:US
Mailing Address - Phone:719-645-9426
Mailing Address - Fax:
Practice Address - Street 1:6385 CORPORATE DR STE 200-41
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-5901
Practice Address - Country:US
Practice Address - Phone:719-341-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician