Provider Demographics
NPI:1598180143
Name:BLACK-RYEL, AMY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLACK-RYEL
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 1:2416 ELKHORN RANCH ST
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-4229
Mailing Address - Country:US
Mailing Address - Phone:303-378-7813
Mailing Address - Fax:720-324-4902
Practice Address - Street 1:2416 ELKHORN RANCH ST
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-4229
Practice Address - Country:US
Practice Address - Phone:303-378-7813
Practice Address - Fax:720-324-4902
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14030448235Z00000X
COSLP.0001505235Z00000X
CO0001505235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79204767Medicaid