Provider Demographics
NPI:1497967350
Name:TREIDE, ELLEN C (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:TREIDE
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 1:12 THUNDERBIRD DR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-8936
Mailing Address - Country:US
Mailing Address - Phone:307-763-3546
Mailing Address - Fax:
Practice Address - Street 1:12 THUNDERBIRD DR
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8936
Practice Address - Country:US
Practice Address - Phone:307-763-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4452235Z00000X
WYSP-499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist