Provider Demographics
NPI:1679522817
Name:PSYCHOLOGICAL SERVICES, P.C.
Entity type:Organization
Organization Name:PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SOPER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:303-443-1223
Mailing Address - Street 1:613 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5031
Mailing Address - Country:US
Mailing Address - Phone:303-443-1223
Mailing Address - Fax:303-473-9153
Practice Address - Street 1:613 WALNUT ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5031
Practice Address - Country:US
Practice Address - Phone:303-443-1223
Practice Address - Fax:303-473-9153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO633 AND 1746103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04010732Medicaid
CO04010732Medicaid