Provider Demographics
NPI:1114130028
Name:ELLIS, JOAN J
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:J
Last Name:ELLIS
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 71
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:ME
Mailing Address - Zip Code:04449-0071
Mailing Address - Country:US
Mailing Address - Phone:207-327-2183
Mailing Address - Fax:
Practice Address - Street 1:88 HAMMOND ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4953
Practice Address - Country:US
Practice Address - Phone:207-461-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME025193Medicare UPIN