Provider Demographics
NPI:1093443251
Name:ELLISON, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 627
Mailing Address - Street 2:
Mailing Address - City:EAST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02536-0627
Mailing Address - Country:US
Mailing Address - Phone:508-954-9718
Mailing Address - Fax:
Practice Address - Street 1:12380 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2511
Practice Address - Country:US
Practice Address - Phone:314-447-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022024563235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist