MEDICARE: COLORADO SPEECH THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency		CO

General Provider Information

NPI Number	:	1538566864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO SPEECH THERAPY LLC

Provider Business Mailing Address
First Line	:	700 BRAMBLEBUSH ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-2199
Country	:	US
Telephone Number	:	970-227-7731
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 BRAMBLEBUSH ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-2199
Country	:	US
Telephone Number	:	970-227-7731
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STACIE IVEY
Credential	:
Telephone Number	:	970-227-7731

Provider Enumeration Date	:	12/02/2014
Last Update Date	:	12/02/2014

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