Provider Demographics
NPI:1760024624
Name:DAMICO, MOLLY (MS SLP, CLC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:DAMICO
Suffix:
Gender:F
Credentials:MS SLP, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4227
Practice Address - Country:US
Practice Address - Phone:970-384-7550
Practice Address - Fax:970-384-8162
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO354296174N00000X
COSLP.0004469235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN