Provider Demographics
NPI:1972879377
Name:ELLENBOGEN, RACHEL EMMA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:EMMA
Last Name:ELLENBOGEN
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 1:200 E 72ND ST
Mailing Address - Street 2:5M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4537
Mailing Address - Country:US
Mailing Address - Phone:908-461-4945
Mailing Address - Fax:
Practice Address - Street 1:1 HERNANDEZ CT
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-4406
Practice Address - Country:US
Practice Address - Phone:908-461-4945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021691235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist