Healthcare Provider Details

I. General information

NPI: 1598399115
Provider Name (Legal Business Name): PH BALANCE BEHAVIORAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 5TH AVE
LONGMONT CO
80501-5424
US

IV. Provider business mailing address

954 5TH AVE
LONGMONT CO
80501-5424
US

V. Phone/Fax

Practice location:
  • Phone: 720-410-4529
  • Fax:
Mailing address:
  • Phone: 720-410-4529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANDON ARTHUR PEREA-HICKAM
Title or Position: FOUNDER AND CEO
Credential: PHD, BCBA
Phone: 720-410-4529