Provider Demographics
NPI:1992520175
Name:ELLISON, KELSEY MEGAN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MEGAN
Last Name:ELLISON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1219
Mailing Address - Country:US
Mailing Address - Phone:858-334-9192
Mailing Address - Fax:
Practice Address - Street 1:6536 TELEGRAPH AVE STE C101
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1192
Practice Address - Country:US
Practice Address - Phone:707-641-4759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39369235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist