Provider Demographics
NPI:1003108960
Name:ELLIOTT, ANGELA DAWN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 FIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9252
Mailing Address - Country:US
Mailing Address - Phone:719-371-1510
Mailing Address - Fax:888-375-2019
Practice Address - Street 1:1124 FIELD AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9252
Practice Address - Country:US
Practice Address - Phone:719-276-0991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67871879Medicaid