Healthcare Provider Details

I. General information

NPI: 1487066494
Provider Name (Legal Business Name): DEREK CICCHITTO MS, CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2014
Last Update Date: 08/05/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 TENNYSON ST APT 205
DENVER CO
80212-2275
US

IV. Provider business mailing address

1806 N LINCOLN ST FL 11
DENVER CO
80203-7301
US

V. Phone/Fax

Practice location:
  • Phone: 303-746-3960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0000306
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: