Basic Information
| Provider Information | |||||||||
| NPI: | 1760508394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROKENLEG | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10350 E DAKOTA AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802471314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10350 E DAKOTA AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802471314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033384545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 05/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 516 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 006894 | 01 | KAISER-COMMERCIAL NUMBER | OTHER |