ICN PLLC (NPI# 1487192076) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1487192076 |
| Entity Type | Organization |
| Organization Name | ICN PLLC |
| Other Organization Name | INSTITUTE FOR CLINICAL NEUROSCIENCES |
| Practice Address |
255 Canyon Blvd Ste 300-f Boulder CO 80302-4979 |
| Mailing Address |
5455 Lee Hill Dr Boulder CO 80302-9305 |
| Practice Telephone | 9725708200 |
| Practice Fax Number | 9724025621 |
| Mailing Telephone | 7205522995 |
| Enumeration Date | 2017-02-03 |
| Last Update Date | 2019-01-02 |
| Authorized Official Name | BOBBY LEE GANT (PRESIDENT) |
| Authorized Official Telephone | 7205522995 |
| Authorized Official Credential | PHD |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 103G00000X | Clinical Neuropsychologist | 2998 | CO | Behavioral Health & Social Service Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| CO | 9000167953 | 05 |
| Other Name | Type Code |
|---|---|
| Institute for Clinical Neurosciences | Doing Business As Name - Organization |
| Street Address |
255 CANYON BLVD STE 300-F |
| City | BOULDER |
| State | CO |
| Zip Code | 80302-4979 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1093323347 | Aviva Naomi Bannerman | Counselor | 2299pearlst., Boulder, CO 80302 | 2020-07-22 |
| 1205480845 | Mark L Sipowicz | Counselor | 100 Arapahoe Avenue, Boulder, CO 80302 | 2019-08-01 |
| 1366909806 | Brett Adamek | Counselor | 2027 Broadway, Suite E, Boulder, CO 80302 | 2019-02-20 |
| 1124592225 | Stepheny Antrobus | Counselor | 100 Arapahoe Lane, Suite 12, Boulder, CO 80302 | 2019-01-11 |
| 1942721337 | Sasha Marvel Hope | Nutritionist | 2260 Baseline Road #102, Boulder, CO 80302 | 2017-07-06 |
| 1073045365 | Mark Shusterman | Internal Medicine | 2133 5th Street, Boulder, CO 80302 | 2017-03-28 |
| 1316489396 | Agnieszka Spuzak | Nutritionist | 1267 Fourmile Canyon Dr, Boulder, CO 80302 | 2016-11-08 |
| 1265980031 | Tanya Robertson | Physical Therapy Assistant | 1633 Grove Street, Boulder, CO 80302 | 2016-09-21 |
| 1699142380 | Libbey Occupational Therapy Services LLC | Occupational Therapist | 100 West Arapahoe Ln, Suite 12, Boulder, CO 80302 | 2015-08-28 |
| 1831597244 | Annemarie Curran Prairie | Counselor | 2505 Walnut St., Ste 303, Boulder, CO 80302 | 2014-12-17 |
| Find all providers in zip 80302 | ||||
| Taxonomy Code | 103G00000X |
| Grouping | Behavioral Health & Social Service Providers |
| Classification | Clinical Neuropsychologist |
| An individual with a doctorate degree, licensure in clinical psychology and specialized training or board certification in neuropsychology who practices or adheres to the principles of neuropsychology; a specialty within the field of psychology focusing primarily on neurobehavioral functioning. |
| Notes: Source: American Psychological Association, Washington, DC, 1997. [1/1/2007: title modified] |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1255848321 | Jill Gitten Aloia | Clinical Neuropsychologist | 2501 Walnut St Ste 102, Boulder, CO 80302-5752 | 2018-01-10 |
| 1720537467 | Zachary Sussman | Clinical Neuropsychologist | 2501 Walnut St Ste 104, Boulder, CO 80302-5752 | 2016-09-22 |
| 1952680829 | Karen M Mikolic | Clinical Neuropsychologist | 3050 Broadway St., Boulder, CO 80304-3154 | 2011-08-10 |
| 1730414657 | Pg Neuropsychology | Clinical Neuropsychologist | 433 Mapleton Ave Apt A, Boulder, CO 80304-3994 | 2009-10-09 |
| 1144340365 | Robert B Mcintyre | Clinical Neuropsychologist | 2305 Canyon Blvd Ste 205, Boulder, CO 80302-5655 | 2007-03-30 |
| 1609923721 | Michele L. Gerard | Clinical Neuropsychologist | 1750 30th St # 224, Boulder, CO 80301-1029 | 2007-01-03 |
| 1326104415 | Bobby Lee Gant | Clinical Neuropsychologist | 255 Canyon Blvd Ste 300f, Boulder, CO 80302 | 2006-12-31 |
| 1316024110 | Emily D. Richardson | Clinical Neuropsychologist | 345 Ucb, Muenzinger D232a, Boulder, CO 80309-0345 | 2006-11-01 |
| 1811079494 | Kathryn Kaye | Clinical Neuropsychologist | 2501 Walnut St Ste 201, Boulder, CO 80302-5753 | 2006-10-20 |
| 1245264571 | Neuropsychological Consultants, L.L.C. | Clinical Neuropsychologist | 1919 14th St Ste 812, Boulder, CO 80302-5310 | 2006-07-11 |
| Find all providers in BOULDER | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.