Healthcare Provider Details

I. General information

NPI: 1619682978
Provider Name (Legal Business Name): AVERY POLK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 N LINCOLN ST
DENVER CO
80203-7301
US

IV. Provider business mailing address

122 DARTEZE DR
LAFAYETTE LA
70508-8111
US

V. Phone/Fax

Practice location:
  • Phone: 720-423-3200
  • Fax:
Mailing address:
  • Phone: 337-541-8519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8833
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number24492689
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: