MEDICARE: COLLEEN M. HART MACCCSLP

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	SLP0188	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	463315	OTHER	AZ	AHCCCS
2	AZ0143390	OTHER	AZ	BLUE CROSS/BLUE SHIELD ID

General Provider Information

NPI Number	:	1720083009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN M. HART MACCCSLP

Provider Business Mailing Address
First Line	:	1031 W INDIAN HILLS PL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-6278
Country	:	US
Telephone Number	:	602-243-8600
Fax Number	:

Provider Business Practice Location Address
First Line	:	1031 W INDIAN HILLS PL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-6278
Country	:	US
Telephone Number	:	602-243-8600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	07/08/2007

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