Provider Demographics
NPI:1821409228
Name:ELLIS, NIKKI LEIGH (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:LEIGH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:LEIGH
Other - Last Name:JUSTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:3107 SUSAN DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-9019
Mailing Address - Country:US
Mailing Address - Phone:440-781-1057
Mailing Address - Fax:
Practice Address - Street 1:4624 SUMMERDALE DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:850-994-3456
Practice Address - Fax:850-994-3476
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13813252Y00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency