Provider Demographics
NPI:1932307147
Name:ESPINOSA, ELLEN (SLP)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:ESPINOSA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12708 PIRU BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3825
Mailing Address - Country:US
Mailing Address - Phone:505-294-3314
Mailing Address - Fax:
Practice Address - Street 1:300 N 9TH ST
Practice Address - Street 2:
Practice Address - City:ESTANCIA
Practice Address - State:NM
Practice Address - Zip Code:87016
Practice Address - Country:US
Practice Address - Phone:505-384-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM454235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z2752Medicaid