Healthcare Provider Details

I. General information

NPI: 1033810437
Provider Name (Legal Business Name): PURPLE MOUNTAIN SPEECH CLINIC, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6985 CABRIOLET DR
COLORADO SPRINGS CO
80923-8797
US

IV. Provider business mailing address

6985 CABRIOLET DR
COLORADO SPRINGS CO
80923-8797
US

V. Phone/Fax

Practice location:
  • Phone: 719-204-5236
  • Fax:
Mailing address:
  • Phone: 719-204-5236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN G HEACOCK
Title or Position: CEO
Credential:
Phone: 719-204-5236