Provider Demographics
NPI:1578551024
Name:UNIVERSITY OF NORTHERN COLORADO
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTHERN COLORADO
Other - Org Name:SPEECH & AUDIOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE VP ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-351-3966
Mailing Address - Street 1:501 20TH ST
Mailing Address - Street 2:55
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80639-0001
Mailing Address - Country:US
Mailing Address - Phone:970-351-2012
Mailing Address - Fax:970-351-1601
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:55
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80639-0001
Practice Address - Country:US
Practice Address - Phone:970-351-2012
Practice Address - Fax:970-351-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04439097Medicaid
CO04439097Medicaid