Provider Demographics
NPI:1487192076
Name:ICN PLLC
Entity Type:Organization
Organization Name:ICN PLLC
Other - Org Name:INSTITUTE FOR CLINICAL NEUROSCIENCES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:720-552-2995
Mailing Address - Street 1:5455 LEE HILL DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9305
Mailing Address - Country:US
Mailing Address - Phone:720-552-2995
Mailing Address - Fax:
Practice Address - Street 1:255 CANYON BLVD STE 300-F
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-4979
Practice Address - Country:US
Practice Address - Phone:972-570-8200
Practice Address - Fax:972-402-5621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2998103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000167953Medicaid