Provider Demographics
NPI:1407304819
Name:MATTORANO, COREY POE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:POE
Last Name:MATTORANO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 E DESERT COVE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6521
Mailing Address - Country:US
Mailing Address - Phone:505-358-0623
Mailing Address - Fax:
Practice Address - Street 1:704 FORTINO BLVD STE A
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2087
Practice Address - Country:US
Practice Address - Phone:719-305-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-6059235Z00000X
COSLP.0003056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000162889Medicaid