Provider Demographics
NPI:1891963278
Name:COLETTE ELLIS M.ED., CCC-SLP & ASSOCIATES
Entity Type:Organization
Organization Name:COLETTE ELLIS M.ED., CCC-SLP & ASSOCIATES
Other - Org Name:29TH STREET THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:405-224-0002
Mailing Address - Street 1:1211 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-9651
Mailing Address - Country:US
Mailing Address - Phone:405-224-0002
Mailing Address - Fax:405-224-0133
Practice Address - Street 1:1211 S 29TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-9651
Practice Address - Country:US
Practice Address - Phone:405-224-0002
Practice Address - Fax:405-224-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty