Provider Demographics
NPI:1831804277
Name:DORN, GENEVIEVE NICOLE
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:NICOLE
Last Name:DORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 FRONTIER ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2405
Mailing Address - Country:US
Mailing Address - Phone:210-860-6822
Mailing Address - Fax:
Practice Address - Street 1:1500 FRONTIER ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2405
Practice Address - Country:US
Practice Address - Phone:210-860-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005144235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist