Provider Demographics
NPI:1104490721
Name:ELLENS, ALEXANDRA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:ELLENS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7514 MADDEN DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-1368
Mailing Address - Country:US
Mailing Address - Phone:317-506-9523
Mailing Address - Fax:
Practice Address - Street 1:7855 S EMERSON AVE STE W
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8669
Practice Address - Country:US
Practice Address - Phone:317-691-4539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007327A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty