Basic Information
| Provider Information | |||||||||
| NPI: | 1962042127 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENTAL HEALTH CENTER OF BOULDER COUNTY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1455 DIXON AVENUE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800268879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034438500 | ||||||||
| FaxNumber: | 3034496029 | ||||||||
| Practice Location | |||||||||
| Address1: | 897 US-287 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800200201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034438500 | ||||||||
| FaxNumber: | 3034496029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2020 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | GERGEN | ||||||||
| AuthorizedOfficialFirstName: | JOANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3034438500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 04988085 | 05 | CO | MEDICAID |