Provider Demographics
NPI:1396879128
Name:ELLIS, AMY L (MNS CCC SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MNS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-1004
Mailing Address - Country:US
Mailing Address - Phone:623-412-1408
Mailing Address - Fax:
Practice Address - Street 1:2850 N 24TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1004
Practice Address - Country:US
Practice Address - Phone:623-412-1408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist