Provider Demographics
NPI:1376159558
Name:DOMINGUEZ, COLETTE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:
Other - Last Name:FORTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:4428 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-1401
Mailing Address - Country:US
Mailing Address - Phone:312-639-3072
Mailing Address - Fax:
Practice Address - Street 1:4428 4TH AVE N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-1401
Practice Address - Country:US
Practice Address - Phone:312-639-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-2868235Z00000X
NMSLP7600235Z00000X
MTSLP-SP-LIC-12202235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist