MEDICARE: DR. AVIVA LARA BASS-HUH PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3039	CO

General Provider Information

NPI Number	:	1497806574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AVIVA LARA BASS-HUH PSY.D.

Provider Business Mailing Address
First Line	:	6644 DREW RANCH LN
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80301-3570
Country	:	US
Telephone Number	:	720-938-3423
Fax Number	:

Provider Business Practice Location Address
First Line	:	6658 GUNPARK DR
Second Line	:	SUITE 202B
City	:	BOULDER
State	:	CO
Zip	:	80301-3385
Country	:	US
Telephone Number	:	720-938-3423
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	04/07/2021

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