Provider Demographics
NPI:1871188458
Name:EDWARD MOCKUS PHD PLLC
Entity type:Organization
Organization Name:EDWARD MOCKUS PHD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOCKUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:720-526-0579
Mailing Address - Street 1:5277 MANHATTAN CIR STE 102
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-8200
Mailing Address - Country:US
Mailing Address - Phone:720-526-0579
Mailing Address - Fax:
Practice Address - Street 1:5277 MANHATTAN CIR STE 102
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-8200
Practice Address - Country:US
Practice Address - Phone:720-526-0579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty