Provider Demographics
NPI:1205480845
Name:SIPOWICZ, MARK L (REGISTERED THERAPIST)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:SIPOWICZ
Suffix:
Gender:M
Credentials:REGISTERED THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BLUEBELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302
Mailing Address - Country:US
Mailing Address - Phone:650-228-8286
Mailing Address - Fax:
Practice Address - Street 1:100 ARAPAHOE AVENUE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302
Practice Address - Country:US
Practice Address - Phone:650-228-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0107125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health