Provider Demographics
NPI:1568731941
Name:UNIVERSITY OF COLORADO, BOULDER'S WOMEN'S MENTAL HEALTH & WELLNESS CLI
Entity Type:Organization
Organization Name:UNIVERSITY OF COLORADO, BOULDER'S WOMEN'S MENTAL HEALTH & WELLNESS CLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SONA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMIDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-492-3485
Mailing Address - Street 1:DEPT OF PSYCHOLOGY AND NEUROSCIENCE
Mailing Address - Street 2:BOX 345 UCB
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80309-0345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1777 EXPOSITION DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2628
Practice Address - Country:US
Practice Address - Phone:303-492-7378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3309302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization