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General NPI Number Information
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NPI Number | 1528676616
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE PSYCHIATRY CENTER OF BOULDER LLC
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Dates
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Enumeration Date | 07/15/2020
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Last Update Date | 07/15/2020
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Provider Practice Location Address
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Address Line | 5420 ARAPAHOE AVE STE 1
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City | BOULDER
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State | CO
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Zip | 80303-1250
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Country | US
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Telephone | 303-260-9685
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Fax |
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Provider Business Mailing Address
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Address Line | 5420 ARAPAHOE AVE STE 1
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City | BOULDER
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State | CO
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Zip | 80303-1250
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Country | US
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Telephone | 303-260-9685
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JOSEPH WILLIAM VAN DERVEER III
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Credential | MD
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Telephone | 303-260-9685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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