Provider Demographics
NPI:1386276004
Name:DUTKO, ALEXIS ELIZABETH (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:ELIZABETH
Last Name:DUTKO
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 1:4512 E 12TH ST UNIT 6
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6782
Mailing Address - Country:US
Mailing Address - Phone:304-261-1076
Mailing Address - Fax:
Practice Address - Street 1:1200 E 20TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3979
Practice Address - Country:US
Practice Address - Phone:307-773-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP-951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist