MEDICARE: MIGHTY MOUTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	01096989	CO

General Provider Information

NPI Number	:	1558877167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIGHTY MOUTH LLC

Provider Business Mailing Address
First Line	:	6086 S ALTON WAY
Second Line	:
City	:	GREENWOOD VILLAGE
State	:	CO
Zip	:	80111-5223
Country	:	US
Telephone Number	:	720-933-7447
Fax Number	:

Provider Business Practice Location Address
First Line	:	6086 S ALTON WAY
Second Line	:
City	:	GREENWOOD VILLAGE
State	:	CO
Zip	:	80111-5223
Country	:	US
Telephone Number	:	720-933-7447
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUSANA DUGAS
Credential	:	MA, CCC-SLP
Telephone Number	:	720-933-7447

Provider Enumeration Date	:	12/19/2017
Last Update Date	:	12/19/2017

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Directions to “MIGHTY MOUTH LLC ” Practice Location

Language	Start Address	Practice Location

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