Provider Demographics
NPI:1558852525
Name:GOTTLIEB, MARI ANNE (MA-CCC SLP)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:ANNE
Last Name:GOTTLIEB
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 1:700 HAWTHORN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-2140
Mailing Address - Country:US
Mailing Address - Phone:269-369-1679
Mailing Address - Fax:
Practice Address - Street 1:1136 E STUART ST STE 3120
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1196
Practice Address - Country:US
Practice Address - Phone:970-682-3743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSLP.0000217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist