Provider Demographics
NPI:1700428760
Name:FISKE, BREANNA L
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:L
Last Name:FISKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7205 W 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2358
Mailing Address - Country:US
Mailing Address - Phone:303-665-6800
Mailing Address - Fax:303-265-9820
Practice Address - Street 1:1650 W 121ST AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-2302
Practice Address - Country:US
Practice Address - Phone:303-665-6800
Practice Address - Fax:303-265-9820
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-19-84095106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician