Provider Demographics
NPI:1245245117
Name:DELUCA, JOHN WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:DELUCA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18553
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-1553
Mailing Address - Country:US
Mailing Address - Phone:303-746-4402
Mailing Address - Fax:
Practice Address - Street 1:1800 30TH ST
Practice Address - Street 2:SUITE 207
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1088
Practice Address - Country:US
Practice Address - Phone:303-746-4402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2846103G00000X
MI6301006649103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist