Provider Demographics
NPI:1649043142
Name:MATTIMORE, GRACE (SLP-CCC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MATTIMORE
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 S UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-6031
Mailing Address - Country:US
Mailing Address - Phone:574-807-4080
Mailing Address - Fax:
Practice Address - Street 1:4704 HARLAN ST STE 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80212-7417
Practice Address - Country:US
Practice Address - Phone:303-433-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0006129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist