Provider Demographics
NPI:1851081590
Name:ELLIS, NIKKI (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:NIKKI
Middle Name:
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 1:124 STONE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9771
Mailing Address - Country:US
Mailing Address - Phone:304-673-0829
Mailing Address - Fax:
Practice Address - Street 1:301 PARK AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-5355
Practice Address - Country:US
Practice Address - Phone:304-256-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist