Provider Demographics
NPI:1609146588
Name:ELLENIS, SUSAN ANN (MS)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ANN
Last Name:ELLENIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BRIAN LN
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3810
Mailing Address - Country:US
Mailing Address - Phone:631-486-1079
Mailing Address - Fax:
Practice Address - Street 1:25 BRIAN LN
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-3810
Practice Address - Country:US
Practice Address - Phone:631-486-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4719235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist