Provider Demographics
NPI:1518539220
Name:ELLINGSON, MARY T (MS, SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0574
Mailing Address - Country:US
Mailing Address - Phone:701-222-3175
Mailing Address - Fax:701-222-3186
Practice Address - Street 1:2080 36TH AVE SW STE 110
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7597
Practice Address - Country:US
Practice Address - Phone:701-222-3175
Practice Address - Fax:701-222-3186
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1483043Medicaid