Provider Demographics
NPI:1174951164
Name:BONNICKSEN, COLLEEN ROSE WITT (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ROSE WITT
Last Name:BONNICKSEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 S ALTON WAY # 250
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-2201
Mailing Address - Country:US
Mailing Address - Phone:720-488-9040
Mailing Address - Fax:
Practice Address - Street 1:6121 COBURG LN
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-9501
Practice Address - Country:US
Practice Address - Phone:499-933-4152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001571235Z00000X
MA8963235Z00000X
MO2019031366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist