Provider Demographics
NPI:1902014624
Name:BECKER, MARY GAIL (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARY GAIL
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 ROBB ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2184
Mailing Address - Country:US
Mailing Address - Phone:303-278-7418
Mailing Address - Fax:888-341-5050
Practice Address - Street 1:4685 BASELINE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2601
Practice Address - Country:US
Practice Address - Phone:303-494-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006056L103T00000X
COPSY.0003825103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPSY.0003825OtherPROFESSIONAL LICENSE