Provider Demographics
NPI:1598039190
Name:INTERACTIVE BRAIN ANALYSIS
Entity Type:Organization
Organization Name:INTERACTIVE BRAIN ANALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-447-8443
Mailing Address - Street 1:4885 RIVERBEND RD
Mailing Address - Street 2:SUITE D300
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2617
Mailing Address - Country:US
Mailing Address - Phone:303-447-8443
Mailing Address - Fax:
Practice Address - Street 1:4885 RIVERBEND RD
Practice Address - Street 2:SUITE D300
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2617
Practice Address - Country:US
Practice Address - Phone:303-447-8443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3408101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty