Provider Demographics
NPI:1922230010
Name:ELLIS, CHARLES CARLISLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:CARLISLE
Last Name:ELLIS
Suffix:
Gender:M
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:PO BOX 20192
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93390-0192
Mailing Address - Country:US
Mailing Address - Phone:661-747-3236
Mailing Address - Fax:661-588-4242
Practice Address - Street 1:14015 SANTA FE CT
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93314-8357
Practice Address - Country:US
Practice Address - Phone:661-747-3236
Practice Address - Fax:661-588-4242
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-22
Last Update Date:2009-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP4590235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist