MEDICARE: EDWARD PHILLIP MOCKUS PHD

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	0004518	CO

General Provider Information

NPI Number	:	1902213655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD PHILLIP MOCKUS PHD

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2014
Last Update Date	:	03/04/2021

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Directions to “ EDWARD PHILLIP MOCKUS PHD” Practice Location

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