1407304819 NPI number — COREY POE MATTORANO MS. CCC-SLP

Table of content: COREY POE MATTORANO MS. CCC-SLP (NPI 1407304819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407304819 NPI number — COREY POE MATTORANO MS. CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTORANO
Provider First Name:
COREY
Provider Middle Name:
POE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS. CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407304819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1129 E DESERT COVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO WEST
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81007-6521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-358-0623
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
704 FORTINO BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-2087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-305-8300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  C-6059 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SLP.0003056 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9000162889 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com