Provider Demographics
NPI:1265047849
Name:ELLIS, ALLISON (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:ELLIS
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 1:459 JAMES P BRAWLEY DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-6801
Mailing Address - Country:US
Mailing Address - Phone:678-567-6883
Mailing Address - Fax:
Practice Address - Street 1:3597 KESWICK DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-2003
Practice Address - Country:US
Practice Address - Phone:678-585-4715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008873235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty