Provider Demographics
NPI:1174197370
Name:ELLIS, LOGAN MACRAE (MA ED, CF-SLP)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:MACRAE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA ED, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 BLAZER PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2117
Mailing Address - Country:US
Mailing Address - Phone:859-225-5424
Mailing Address - Fax:
Practice Address - Street 1:3280 BLAZER PKWY STE 101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2117
Practice Address - Country:US
Practice Address - Phone:859-225-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY270292235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist