Provider Demographics
NPI:1508390964
Name:ELLICOTT, RENEE
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:
Last Name:ELLICOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:ROUSSEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:70 LIBERTY COMMON
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NH
Mailing Address - Zip Code:03870
Mailing Address - Country:US
Mailing Address - Phone:603-553-0589
Mailing Address - Fax:
Practice Address - Street 1:70 LIBERTY CMN
Practice Address - Street 2:
Practice Address - City:RYE
Practice Address - State:NH
Practice Address - Zip Code:03870-2013
Practice Address - Country:US
Practice Address - Phone:603-553-0589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5223235Z00000X
NH0768235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist