Healthcare Provider Details

I. General information

NPI: 1730049115
Provider Name (Legal Business Name): PEDIATRIC NEUROLOGY AND EPILEPSY SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 N BOISE AVE
LOVELAND CO
80538-5037
US

IV. Provider business mailing address

9235 N UNION BLVD STE 150334
COLORADO SPRINGS CO
80920-7831
US

V. Phone/Fax

Practice location:
  • Phone: 303-226-7230
  • Fax:
Mailing address:
  • Phone: 303-226-7230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALICIA LICANO
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 719-638-1122