Provider Demographics
NPI:1477744688
Name:ELLIS, LISA MARGARET
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARGARET
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4617
Mailing Address - Country:US
Mailing Address - Phone:813-662-1060
Mailing Address - Fax:
Practice Address - Street 1:206 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4617
Practice Address - Country:US
Practice Address - Phone:813-662-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ-4246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist