Provider Demographics
NPI:1871618108
Name:GACNIK, KAREN MALOTT (MS CCC-A)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:MALOTT
Last Name:GACNIK
Suffix:
Gender:F
Credentials:MS CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 FORTINO BLVD
Mailing Address - Street 2:STE. D
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2084
Mailing Address - Country:US
Mailing Address - Phone:719-542-1760
Mailing Address - Fax:179-542-5115
Practice Address - Street 1:712 FORTINO BLVD
Practice Address - Street 2:STE. D
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2084
Practice Address - Country:US
Practice Address - Phone:719-542-1760
Practice Address - Fax:179-542-5115
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO471231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00200291OtherRR MEDICARE
C521668Medicare PIN