Healthcare Provider Details

I. General information

NPI: 1558035840
Provider Name (Legal Business Name): AUTUMN HAYLEY TRACY CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN HUTSON

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 E FLORIDA AVE STE 917
DENVER CO
80210-2549
US

IV. Provider business mailing address

3801 E FLORIDA AVE STE 917
DENVER CO
80210-2549
US

V. Phone/Fax

Practice location:
  • Phone: 844-757-7450
  • Fax:
Mailing address:
  • Phone: 844-757-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0004508
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: