Provider Demographics
NPI:1316043235
Name:EMMANUEL, ELLI (MA CCC /SLP)
Entity Type:Individual
Prefix:MS
First Name:ELLI
Middle Name:
Last Name:EMMANUEL
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 1:1440 PARK SHORE CIR
Mailing Address - Street 2:#1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9614
Mailing Address - Country:US
Mailing Address - Phone:239-826-3593
Mailing Address - Fax:
Practice Address - Street 1:1440 PARK SHORE CIR
Practice Address - Street 2:#1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9614
Practice Address - Country:US
Practice Address - Phone:239-826-3593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1179235Z00000X
104100000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001505300Medicaid
FL812311000Medicaid
FL880500800Medicaid