Basic Information
Provider Information | |||||||||
NPI: | 1538396296 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLETTI | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S.,CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMOKOSKI | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | L. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S., CCC-SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2603 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761132603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175694396 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3840 HULEN ST | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761077277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175694396 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2009 | ||||||||
LastUpdateDate: | 02/29/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 15133 | TX | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 202957101 | 05 | TX |   | MEDICAID | 8OT345 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |