Provider Demographics
NPI:1922358407
Name:ELLRICH, KIMBERLY LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:ELLRICH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 MOHAWK HILLS DRIVE
Mailing Address - Street 2:APT D
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032
Mailing Address - Country:US
Mailing Address - Phone:765-366-1587
Mailing Address - Fax:
Practice Address - Street 1:STORYPOINT
Practice Address - Street 2:3951 W MILHAM AVE
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-329-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002371A235Z00000X
MI7101006077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist