Provider Demographics
NPI:1558406082
Name:MILLER, IVAN JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:JOSEPH
Last Name:MILLER
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 1:350 NORTH BROADWAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3338
Mailing Address - Country:US
Mailing Address - Phone:303-499-3888
Mailing Address - Fax:303-494-3837
Practice Address - Street 1:350 NORTH BROADWAY
Practice Address - Street 2:SUITE 210
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3338
Practice Address - Country:US
Practice Address - Phone:303-499-3888
Practice Address - Fax:303-494-3837
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1398103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86596Medicare ID - Type UnspecifiedPSYCHOLOGIST