Provider Demographics
NPI:1922015387
Name:MCLANE, MANDY MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:MARIE
Last Name:MCLANE
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 1:1603 TURIN DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-2717
Mailing Address - Country:US
Mailing Address - Phone:407-252-8905
Mailing Address - Fax:303-501-1720
Practice Address - Street 1:1603 TURIN DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-2717
Practice Address - Country:US
Practice Address - Phone:407-252-8905
Practice Address - Fax:303-501-1720
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000140235Z00000X
FLSA 8295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93231067Medicaid
FL8903590.00Medicaid