Provider Demographics
NPI:1710494083
Name:DAILEY, ANGIE CRISTIN (SLP)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:CRISTIN
Last Name:DAILEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 2142
Mailing Address - Street 2:1 JACKSON CREEK RD
Mailing Address - City:CLANCY
Mailing Address - State:MT
Mailing Address - Zip Code:59634
Mailing Address - Country:US
Mailing Address - Phone:303-870-3513
Mailing Address - Fax:
Practice Address - Street 1:PMB 2142
Practice Address - Street 2:1 JACKSON CREEK RD
Practice Address - City:CLANCY
Practice Address - State:MT
Practice Address - Zip Code:59634
Practice Address - Country:US
Practice Address - Phone:303-870-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-5280235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist