Icn PLLC

Primary specialty

Clinical NeuropsychologistTaxonomy code 103G00000X

License

2998 Issued in CO

Legal business name

ICN PLLC

Practice address

255 Canyon Blvd Ste 300-F
Boulder, CO 80302-4979

Phone

(972) 570-8200

Fax

(972) 402-5621

NPI assigned

Feb 3, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Bobby Lee Gant, PHD

Title

President

Phone

(720) 552-2995

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Institute for Clinical Neurosciences Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1486080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1546387200000",
    "number": "1487192076",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5455 LEE HILL DR",
            "city": "BOULDER",
            "state": "CO",
            "postal_code": "803029305",
            "telephone_number": "720-552-2995"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "255 CANYON BLVD STE 300-F",
            "city": "BOULDER",
            "state": "CO",
            "postal_code": "803024979",
            "telephone_number": "972-570-8200",
            "fax_number": "972-402-5621"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ICN PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-02-03",
        "last_updated": "2019-01-02",
        "status": "A",
        "authorized_official_last_name": "GANT",
        "authorized_official_first_name": "BOBBY",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "720-552-2995",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103G00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Clinical Neuropsychologist",
            "state": "CO",
            "license": "2998",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9000167953",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Institute for Clinical Neurosciences",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Kristina S Hyde, RN/APN
• Pamela Jeane Hyink, SLP
• Ian M Kott DDS PC
• Natalie Mannon Ibrahim, PA-C
• Clayton Ickes, LSW
• Ilya Igolnikov, MD
• Jana Ikeda, D.D.S.
• Eva Ikonen
• Ilyse Bloom, LLC
• John R Imig, M.D.

• Clinical Neuropsychologist in Boulder, CO
• Providers in Boulder, CO by specialty
• Clinical Neuropsychologist in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 2, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.