Provider Demographics
NPI:1407347487
Name:BOULDER VALLEY PSYCHOTHERAPY INC.
Entity Type:Organization
Organization Name:BOULDER VALLEY PSYCHOTHERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:WHITTALL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:720-591-4664
Mailing Address - Street 1:400 E SIMPSON ST. #104
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2359
Mailing Address - Country:US
Mailing Address - Phone:720-591-6444
Mailing Address - Fax:
Practice Address - Street 1:400 E SIMPSON ST. #104
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2359
Practice Address - Country:US
Practice Address - Phone:720-591-6444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79600573Medicaid
1154637189OtherINDIVIDUAL NPI