Provider Demographics
NPI:1013030923
Name:MARS, BRENNAN LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRENNAN
Middle Name:LYNN
Last Name:MARS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 344 4800 BASELINE ROAD, E104
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303
Mailing Address - Country:US
Mailing Address - Phone:303-358-4603
Mailing Address - Fax:
Practice Address - Street 1:4800 BASELINE RD STE E104 PMB 344
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2643
Practice Address - Country:US
Practice Address - Phone:303-358-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2327103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58079831Medicaid
COC64146Medicare PIN