Healthcare Provider Details

I. General information

NPI: 1013030923
Provider Name (Legal Business Name): BRENNAN LYNN MARS PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 BASELINE RD STE E104 PMB 344
BOULDER CO
80303-2643
US

IV. Provider business mailing address

PMB 344 4800 BASELINE ROAD, E104
BOULDER CO
80303
US

V. Phone/Fax

Practice location:
  • Phone: 303-358-4603
  • Fax:
Mailing address:
  • Phone: 303-358-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2327
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier58079831
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: