Provider Demographics
NPI:1316490717
Name:LONGOBARDI, DOROTHY
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:LONGOBARDI
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 1:1244 GILLASPIE DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6600
Mailing Address - Country:US
Mailing Address - Phone:303-494-7317
Mailing Address - Fax:303-494-0653
Practice Address - Street 1:1244 GILLASPIE DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6600
Practice Address - Country:US
Practice Address - Phone:303-494-7317
Practice Address - Fax:303-494-0653
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO230354171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO742161726Medicaid