Healthcare Provider Details

I. General information

NPI: 1750784633
Provider Name (Legal Business Name): ASCEND CHILD DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6672 GUNPARK DR
BOULDER CO
80301-3387
US

IV. Provider business mailing address

9276 NIWOT HILLS DR
NIWOT CO
80503-7380
US

V. Phone/Fax

Practice location:
  • Phone: 303-530-4972
  • Fax:
Mailing address:
  • Phone: 303-530-4972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1-04-1566
License Number StateCA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. WILLIAM FREA
Title or Position: PSYCHOLOGIST
Credential: PH.D., BCBA-D
Phone: 303-530-4972