Provider Demographics
NPI:1598371049
Name:BOULDERWISE COUNSELING, LLC
Entity Type:Organization
Organization Name:BOULDERWISE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:IOANNIDES
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:720-319-7319
Mailing Address - Street 1:6017 S JAMESTOWN WAY
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80016-6202
Mailing Address - Country:US
Mailing Address - Phone:303-720-7319
Mailing Address - Fax:303-379-4607
Practice Address - Street 1:6017 S JAMESTOWN WAY
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80016-6202
Practice Address - Country:US
Practice Address - Phone:720-319-7319
Practice Address - Fax:303-379-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1285639567OtherPERSONAL NPI