Provider Demographics
NPI:1497215941
Name:ELLIS, KAITLYN M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-5058
Mailing Address - Country:US
Mailing Address - Phone:325-692-4053
Mailing Address - Fax:
Practice Address - Street 1:2501 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79602-5058
Practice Address - Country:US
Practice Address - Phone:325-692-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111509235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist