Healthcare Provider Details

I. General information

NPI: 1487192076
Provider Name (Legal Business Name): ICN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 CANYON BLVD STE 300-F
BOULDER CO
80302-4979
US

IV. Provider business mailing address

5455 LEE HILL DR
BOULDER CO
80302-9305
US

V. Phone/Fax

Practice location:
  • Phone: 972-570-8200
  • Fax: 972-402-5621
Mailing address:
  • Phone: 720-552-2995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2998
License Number StateCO

VIII. Authorized Official

Name: BOBBY LEE GANT
Title or Position: PRESIDENT
Credential: PHD
Phone: 720-552-2995