Provider Demographics
NPI:1902213655
Name:MOCKUS, EDWARD PHILLIP (PHD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:PHILLIP
Last Name:MOCKUS
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 1:5277 MANHATTAN CIR STE 102
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-8200
Mailing Address - Country:US
Mailing Address - Phone:720-526-0579
Mailing Address - Fax:
Practice Address - Street 1:5277 MANHATTAN CIR STE 102
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-8200
Practice Address - Country:US
Practice Address - Phone:720-526-0579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004518103T00000X
MD05848103TC0700X, 103TC2200X, 103TF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program