Provider Demographics
NPI:1104069335
Name:KRISTIN BROUSSEAU, DO, PC
Entity type:Organization
Organization Name:KRISTIN BROUSSEAU, DO, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:720-938-6720
Mailing Address - Street 1:2501 WALNUT ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5751
Mailing Address - Country:US
Mailing Address - Phone:720-223-7877
Mailing Address - Fax:888-873-4912
Practice Address - Street 1:2501 WALNUT ST
Practice Address - Street 2:SUITE 108
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5751
Practice Address - Country:US
Practice Address - Phone:720-223-7877
Practice Address - Fax:888-873-4912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO407992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty