Healthcare Provider Details

I. General information

NPI: 1881632578
Provider Name (Legal Business Name): COLLEEN ROBBINS POUQUETTE MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 VALLEY ST
PRESCOTT AZ
86305-1826
US

IV. Provider business mailing address

PO BOX 11312
PRESCOTT AZ
86304-1312
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-1309
  • Fax: 928-445-0914
Mailing address:
  • Phone: 928-445-1309
  • Fax: 928-445-0914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberAZSLP0044
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: