Provider Demographics
NPI:1841330081
Name:AUSTIN, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:AUSTIN
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 1:381 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:163 LIBBEY INDUSTRIAL PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3137
Practice Address - Country:US
Practice Address - Phone:781-335-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5538235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASP0195OtherBCBS PROVIDER ID