Healthcare Provider Details

I. General information

NPI: 1427346873
Provider Name (Legal Business Name): THE BOULDER INSTITUTE FOR PSYCHOTHERAPY AND RESEARCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 PINE ST
BOULDER CO
80302-4809
US

IV. Provider business mailing address

1240 PINE ST
BOULDER CO
80302-4809
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-4562
  • Fax: 303-444-2843
Mailing address:
  • Phone: 303-442-4562
  • Fax: 303-444-2843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number20113020808
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. CYNTHIA DIVINO
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 303-442-4562