Provider Demographics
NPI:1720083009
Name:HART, COLLEEN M (MACCCSLP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:HART
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 W INDIAN HILLS PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-6278
Mailing Address - Country:US
Mailing Address - Phone:602-243-8600
Mailing Address - Fax:
Practice Address - Street 1:1031 W INDIAN HILLS PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-6278
Practice Address - Country:US
Practice Address - Phone:602-243-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0188235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ463315OtherAHCCCS
AZAZ0143390OtherBLUE CROSS/BLUE SHIELD ID