Provider Demographics
NPI:1053195701
Name:VANDENBOSCH, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:VANDENBOSCH
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 1:1437 DENVER AVE # 325
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-5226
Mailing Address - Country:US
Mailing Address - Phone:970-221-4057
Mailing Address - Fax:
Practice Address - Street 1:3000 S COLLEGE AVE UNIT 202
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2558
Practice Address - Country:US
Practice Address - Phone:970-221-4057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.0009924977101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)