Provider Demographics
NPI:1811188626
Name:ELLSWORTH, TINA ANDERSON (MS ED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:ANDERSON
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MS ED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 NOB RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5736
Mailing Address - Country:US
Mailing Address - Phone:770-429-0694
Mailing Address - Fax:
Practice Address - Street 1:805 NOB RIDGE DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-5736
Practice Address - Country:US
Practice Address - Phone:770-429-0694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006703235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist