Provider Demographics
NPI:1245629989
Name:ELLIS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-2034
Mailing Address - Country:US
Mailing Address - Phone:620-473-0463
Mailing Address - Fax:
Practice Address - Street 1:600 E GARFIELD ST
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-2034
Practice Address - Country:US
Practice Address - Phone:620-473-0463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2487235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist