Provider Demographics
NPI:1124092283
Name:BROUSSEAU, KRISTIN (DO)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 BLUEBELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-8023
Mailing Address - Country:US
Mailing Address - Phone:303-399-8020
Mailing Address - Fax:303-370-7519
Practice Address - Street 1:1055 CLERMONT ST
Practice Address - Street 2:ROOM 8D128
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3808
Practice Address - Country:US
Practice Address - Phone:303-399-8020
Practice Address - Fax:303-370-7519
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO407992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COH97525Medicare UPIN