Provider Demographics
NPI:1407292311
Name:ELLIS, KRISTIN A (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:A
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 1:731 HAMLET ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2171
Mailing Address - Country:US
Mailing Address - Phone:630-640-0041
Mailing Address - Fax:
Practice Address - Street 1:1519 S GRACE ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4649
Practice Address - Country:US
Practice Address - Phone:630-827-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010971235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist