Provider Demographics
NPI:1821401753
Name:ELLIS, HOLLY LAMB (SLP)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:LAMB
Last Name:ELLIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:MIRANDA
Other - Last Name:LAMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2604 FALLS RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-9875
Mailing Address - Country:US
Mailing Address - Phone:252-342-4189
Mailing Address - Fax:
Practice Address - Street 1:2604 FALLS RIVER AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-9875
Practice Address - Country:US
Practice Address - Phone:252-342-4189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10901235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821401753Medicaid