Provider Demographics
NPI:1851069223
Name:ELLIFRITZ, TODD (HIS)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:
Last Name:ELLIFRITZ
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 POLISH PINES LOOP
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-6702
Mailing Address - Country:US
Mailing Address - Phone:304-413-0184
Mailing Address - Fax:304-413-0185
Practice Address - Street 1:309 POLISH PINES LOOP
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-6702
Practice Address - Country:US
Practice Address - Phone:304-413-0184
Practice Address - Fax:304-413-0185
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1026237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty