Provider Demographics
NPI:1659820405
Name:PONTE, COLLEEN (MA, CCC-SLP/L)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:PONTE
Suffix:
Gender:F
Credentials:MA, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46079 GALWAY DR
Mailing Address - Street 2:46079 GALWAY DR
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-3930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46200 PORT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6048
Practice Address - Country:US
Practice Address - Phone:734-454-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002853235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist