Healthcare Provider Details

I. General information

NPI: 1215669643
Provider Name (Legal Business Name): EMMA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 BASELINE RD STE 200
BOULDER CO
80303-2668
US

IV. Provider business mailing address

4770 BASELINE RD STE 200
BOULDER CO
80303-2668
US

V. Phone/Fax

Practice location:
  • Phone: 970-982-3476
  • Fax: 855-568-2494
Mailing address:
  • Phone: 205-225-8377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: