=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669824918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLORADO COMMUNICATION THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2016
-----------------------------------------------------
Last Update Date | 07/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1312 N LAFAYETTE ST APT 17
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80218-2384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-502-7168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1312 N LAFAYETTE ST APT 17
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80218-2384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-502-7168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREA MILLAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-502-7168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP.0002403
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------