Provider Demographics
NPI:1588063978
Name:EALOM, EMILIA BROADHURST
Entity type:Individual
Prefix:
First Name:EMILIA
Middle Name:BROADHURST
Last Name:EALOM
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 1:4891 INDEPENDENCE ST STE 165
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6714
Mailing Address - Country:US
Mailing Address - Phone:303-456-0600
Mailing Address - Fax:
Practice Address - Street 1:4891 INDEPENDENCE ST STE 165
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6714
Practice Address - Country:US
Practice Address - Phone:303-456-0600
Practice Address - Fax:303-456-0607
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99236341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical