Provider Demographics
NPI:1477162840
Name:WALLACE, ELLEN ANNE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:ANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 LINDELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3304
Mailing Address - Country:US
Mailing Address - Phone:281-995-4631
Mailing Address - Fax:
Practice Address - Street 1:3101 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1931
Practice Address - Country:US
Practice Address - Phone:702-831-6670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist