Provider Demographics
NPI:1801611421
Name:PEDIATRIC NEUROLOGY AND EPILEPSY SPECIALISTS, PLLC
Entity type:Organization
Organization Name:PEDIATRIC NEUROLOGY AND EPILEPSY SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-638-1122
Mailing Address - Street 1:2055 N HIGH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-5568
Mailing Address - Country:US
Mailing Address - Phone:303-226-7230
Mailing Address - Fax:
Practice Address - Street 1:2055 N HIGH ST STE 300
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5568
Practice Address - Country:US
Practice Address - Phone:303-226-7230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty