Provider Demographics
NPI:1689200396
Name:MICKEY, MARKIE RYDHOLM (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARKIE
Middle Name:RYDHOLM
Last Name:MICKEY
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 1:12295 CRABAPPLE ST
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-7975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5699 W 20TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2915
Practice Address - Country:US
Practice Address - Phone:970-451-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-14
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003887235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist