Provider Demographics
NPI:1497935746
Name:PHILLIPS, DOROTHY ANN (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 DIANA ST
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3500
Mailing Address - Country:US
Mailing Address - Phone:970-867-0485
Mailing Address - Fax:
Practice Address - Street 1:1015 DIANA ST
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3500
Practice Address - Country:US
Practice Address - Phone:970-867-0485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-04
Last Update Date:2007-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12023986235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COIN PROCESSMedicaid