Provider Demographics
NPI:1003934878
Name:ELLENBAUM, KELLI KATHARINA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:KATHARINA
Last Name:ELLENBAUM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0574
Mailing Address - Country:US
Mailing Address - Phone:701-222-3175
Mailing Address - Fax:701-222-3186
Practice Address - Street 1:2625 N 19TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0574
Practice Address - Country:US
Practice Address - Phone:701-222-3175
Practice Address - Fax:701-222-3186
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND862235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454835Medicaid
ND27424OtherBCBS ND PROVIDER NUMBER
ND54627Medicaid