MEDICARE: EDWARD MOCKUS PHD PLLC

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1871188458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD MOCKUS PHD PLLC

Provider Business Mailing Address
First Line	:	5277 MANHATTAN CIR STE 102
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-8200
Country	:	US
Telephone Number	:	720-526-0579
Fax Number	:

Provider Business Practice Location Address
First Line	:	5277 MANHATTAN CIR STE 102
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-8200
Country	:	US
Telephone Number	:	720-526-0579
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EDWARD MOCKUS
Credential	:	PHD
Telephone Number	:	720-526-0579

Provider Enumeration Date	:	03/04/2021
Last Update Date	:	03/04/2021

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