Provider Demographics
NPI:1487136065
Name:BORNEMAN, MARY KOELLING (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KOELLING
Last Name:BORNEMAN
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5446
Mailing Address - Country:US
Mailing Address - Phone:678-357-8172
Mailing Address - Fax:
Practice Address - Street 1:1475 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-6029
Practice Address - Country:US
Practice Address - Phone:970-449-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003029235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist