Provider Demographics
NPI:1255610119
Name:ROCKY MOUNTAIN AUDIOLOGY LLC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN AUDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DARIA
Authorized Official - Middle Name:BERNICE
Authorized Official - Last Name:STAKIW
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:970-404-0978
Mailing Address - Street 1:56 EDWARDS VILLAGE BLVD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-7802
Mailing Address - Country:US
Mailing Address - Phone:970-926-6660
Mailing Address - Fax:
Practice Address - Street 1:56 EDWARDS VILLAGE BLVD
Practice Address - Street 2:SUITE 222
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-7802
Practice Address - Country:US
Practice Address - Phone:970-926-6660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAUD391231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83786562Medicaid
CO96822066Medicaid