Provider Demographics
NPI:1518214436
Name:ELLIS, SHIRLEY (SLPD, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:SLPD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N HARLEM ST
Mailing Address - Street 2:
Mailing Address - City:EUDORA
Mailing Address - State:AR
Mailing Address - Zip Code:71640-2755
Mailing Address - Country:US
Mailing Address - Phone:618-306-0889
Mailing Address - Fax:
Practice Address - Street 1:220 N HARLEM ST
Practice Address - Street 2:
Practice Address - City:EUDORA
Practice Address - State:AR
Practice Address - Zip Code:71640-2755
Practice Address - Country:US
Practice Address - Phone:618-306-0889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008667235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12096835OtherAMERICAN SPEECH-LANGUAGE AND HEARING ASSOCIATION