Provider Demographics
NPI:1659400901
Name:WATERS, ELLEN KAY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:KAY
Last Name:WATERS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 N 223RD LN
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:IL
Mailing Address - Zip Code:62360-2414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1202 N 223RD LN
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:IL
Practice Address - Zip Code:62360-2414
Practice Address - Country:US
Practice Address - Phone:217-656-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist