Provider Demographics
NPI:1295215648
Name:ELLIS, KIMBERLEY ANN (MA/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 WOODS CT
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-2915
Mailing Address - Country:US
Mailing Address - Phone:541-387-1949
Mailing Address - Fax:
Practice Address - Street 1:1627 WOODS CT
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2915
Practice Address - Country:US
Practice Address - Phone:541-387-1949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist