Provider Demographics
NPI:1174661615
Name:TAVARES, RITA (SPEECH-LANGUAGE PATH)
Entity Type:Individual
Prefix:MS
First Name:RITA
Middle Name:
Last Name:TAVARES
Suffix:
Gender:F
Credentials:SPEECH-LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 W 27TH ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-8038
Mailing Address - Country:US
Mailing Address - Phone:303-475-7104
Mailing Address - Fax:970-330-4461
Practice Address - Street 1:2423 W 27TH ST
Practice Address - Street 2:UNIT C
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-8038
Practice Address - Country:US
Practice Address - Phone:303-475-7104
Practice Address - Fax:970-330-4461
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO01105095235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37171593Medicaid