Provider Demographics
NPI:1356035133
Name:ELLISON, KATHERINE HOPE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:HOPE
Last Name:ELLISON
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 1:2513 KAILEEN CIR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3005
Mailing Address - Country:US
Mailing Address - Phone:321-480-4108
Mailing Address - Fax:
Practice Address - Street 1:2243 W NEW HAVEN AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3832
Practice Address - Country:US
Practice Address - Phone:321-354-9207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1224237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist