Provider Demographics
NPI:1366007049
Name:ST. JOHN, ELLEN MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARIE
Other - Last Name:PAGANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:7401 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-5227
Mailing Address - Country:US
Mailing Address - Phone:973-864-4371
Mailing Address - Fax:
Practice Address - Street 1:1111 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-4432
Practice Address - Country:US
Practice Address - Phone:727-446-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15738235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist