Provider Demographics
NPI:1639236441
Name:SMITH, ELLEN RENE (MS CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:RENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC-A
Other - Prefix:MRS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:INGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-A
Mailing Address - Street 1:9218 151ST STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-6997
Mailing Address - Country:US
Mailing Address - Phone:253-332-3002
Mailing Address - Fax:
Practice Address - Street 1:9218 151ST STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-6997
Practice Address - Country:US
Practice Address - Phone:253-332-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00003590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist