Provider Demographics
NPI:1457518417
Name:ELLENBECKER, ANGIE DAWN (SLP)
Entity type:Individual
Prefix:MS
First Name:ANGIE
Middle Name:DAWN
Last Name:ELLENBECKER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 SALT LICK TRL
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3321
Mailing Address - Country:US
Mailing Address - Phone:615-596-1830
Mailing Address - Fax:615-766-8277
Practice Address - Street 1:1994 GALLATIN PIKE N STE 309
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2025
Practice Address - Country:US
Practice Address - Phone:615-596-1830
Practice Address - Fax:615-766-8277
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1179235Z00000X
TNST5779235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1457518417Medicaid