Provider Demographics
NPI:1962245126
Name:SPROUTS PSYCHIATRY
Entity type:Organization
Organization Name:SPROUTS PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC PA
Authorized Official - Prefix:
Authorized Official - First Name:SAGE
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:720-618-7098
Mailing Address - Street 1:561 W 173RD PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-5202
Mailing Address - Country:US
Mailing Address - Phone:860-961-8406
Mailing Address - Fax:
Practice Address - Street 1:561 W 173RD PL
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-5202
Practice Address - Country:US
Practice Address - Phone:860-961-8406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-17
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty