Healthcare Provider Details

I. General information

NPI: 1598371049
Provider Name (Legal Business Name): BOULDERWISE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6017 S JAMESTOWN WAY
CENTENNIAL CO
80016-6202
US

IV. Provider business mailing address

6017 S JAMESTOWN WAY
CENTENNIAL CO
80016-6202
US

V. Phone/Fax

Practice location:
  • Phone: 720-319-7319
  • Fax: 303-379-4607
Mailing address:
  • Phone: 303-720-7319
  • Fax: 303-379-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name: JOANNA IOANNIDES
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: MSW, LCSW
Phone: 720-319-7319