=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508547076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFETIME SPEECH AND STUTTERING THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2023
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10996 LIVINGSTON DR
-----------------------------------------------------
City | NORTHGLENN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80234-3384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-790-0831
-----------------------------------------------------
Fax | 303-219-2513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10996 LIVINGSTON DR
-----------------------------------------------------
City | NORTHGLENN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80234-3384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-790-0831
-----------------------------------------------------
Fax | 303-219-2513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | WENDY DIETZ
-----------------------------------------------------
Credential | M.S., CCC-SLP
-----------------------------------------------------
Telephone | 720-838-1346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------