Provider Demographics
NPI:1336797745
Name:ELLIS-JEFFREY, PREMA M (MA)
Entity Type:Individual
Prefix:
First Name:PREMA
Middle Name:M
Last Name:ELLIS-JEFFREY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11721 KEMP MILL RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1722
Mailing Address - Country:US
Mailing Address - Phone:301-649-8085
Mailing Address - Fax:301-649-8092
Practice Address - Street 1:11721 KEMP MILL RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-1722
Practice Address - Country:US
Practice Address - Phone:301-649-8085
Practice Address - Fax:301-649-8092
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist