MEDICARE: FAHTIEEMA OMOTOSHO

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	390200000X	Student in an Organized Health Care Education/Training Program	390200000X
2	235Z00000X	Speech-Language Pathologist	14393767	CO
3	235Z00000X	Speech-Language Pathologist	14393767	NM

General Provider Information

NPI Number	:	1952806010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAHTIEEMA OMOTOSHO

Provider Business Mailing Address
First Line	:	1500 S AVE K STATION 3, SHROC
Second Line	:
City	:	PORTALES
State	:	NM
Zip	:	88130
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 N LINCOLN ST FL 11
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-2996
Country	:	US
Telephone Number	:	720-423-2660
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	02/19/2026

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Directions to “ FAHTIEEMA OMOTOSHO ” Practice Location

Language	Start Address	Practice Location

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