Provider Demographics
NPI:1346315199
Name:ELAM, NANCY REVELLI (MA CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:REVELLI
Last Name:ELAM
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:MISS
Other - First Name:NANCY
Other - Middle Name:ANNE
Other - Last Name:REVELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:191 W BURTON MESA BLVD
Mailing Address - Street 2:CROSS SPEECH & LANGUAGE CENTER STE B
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436
Mailing Address - Country:US
Mailing Address - Phone:805-733-4542
Mailing Address - Fax:805-733-4392
Practice Address - Street 1:191 W BURTON MESA BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-733-4542
Practice Address - Fax:805-733-4392
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP4974235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0663623OtherTRIWEST
CAGSP000390Medicaid
CA0663623OtherTRIWEST