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General NPI Number Information
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NPI Number | 1174951164
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Entity Type | Individual
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Provider Name | COLLEEN ROSE WITT BONNICKSEN M.S. CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 10/29/2013
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Last Update Date | 02/19/2020
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Provider Practice Location Address
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Address Line | 6121 COBURG LN
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City | MISSOULA
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State | MT
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Zip | 59803-9501
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Country | US
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Telephone | 499-933-4152
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Fax |
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Provider Business Mailing Address
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Address Line | 7200 S ALTON WAY # 250
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City | CENTENNIAL
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State | CO
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Zip | 80112-2201
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Country | US
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Telephone | 720-488-9040
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 0001571
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 8963
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2019031366
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License Number State | MO
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