Provider Demographics
NPI:1821297300
Name:ELLIS, MARY LUCENA (MA-CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LUCENA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 45TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5860
Mailing Address - Country:US
Mailing Address - Phone:309-737-6304
Mailing Address - Fax:
Practice Address - Street 1:2810 45TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5860
Practice Address - Country:US
Practice Address - Phone:309-737-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01132235Z00000X
CAMA7678235Z00000X
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist