Provider Demographics
NPI:1255665733
Name:ELLIS, MICHELLE D (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:D
Last Name:ELLIS
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 1:140 E PANHANDLE ST
Mailing Address - Street 2:
Mailing Address - City:SLATON
Mailing Address - State:TX
Mailing Address - Zip Code:79364-4238
Mailing Address - Country:US
Mailing Address - Phone:575-403-8844
Mailing Address - Fax:
Practice Address - Street 1:140 E PANHANDLE ST
Practice Address - Street 2:
Practice Address - City:SLATON
Practice Address - State:TX
Practice Address - Zip Code:79364-4238
Practice Address - Country:US
Practice Address - Phone:806-828-6591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117955235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117955OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION