Provider Demographics
NPI:1568811214
Name:AMODIE, ELLENE AGNES (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:ELLENE
Middle Name:AGNES
Last Name:AMODIE
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 1:2635 YACHT CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4529
Mailing Address - Country:US
Mailing Address - Phone:954-257-4864
Mailing Address - Fax:
Practice Address - Street 1:2635 YACHT CLUB BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-4529
Practice Address - Country:US
Practice Address - Phone:954-257-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6853235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA 6853OtherDEPARTMENT OF HEALTH