Provider Demographics
NPI:1366673071
Name:ELLIS, KRISTA (SPEECH THERAPIST)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3902
Mailing Address - Country:US
Mailing Address - Phone:724-463-7478
Mailing Address - Fax:724-463-0931
Practice Address - Street 1:21 S PINE ST
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520-9720
Practice Address - Country:US
Practice Address - Phone:610-286-0977
Practice Address - Fax:610-286-0986
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396749Medicare PIN