Provider Demographics
NPI:1194204925
Name:TIMOTHY, ELYSE NICOLE (SLP)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:NICOLE
Last Name:TIMOTHY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 ROZINANTE CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-3061
Mailing Address - Country:US
Mailing Address - Phone:801-440-1461
Mailing Address - Fax:
Practice Address - Street 1:8100 MOUNTAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7822
Practice Address - Country:US
Practice Address - Phone:505-344-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist