Provider Demographics
NPI:1154561868
Name:BLACKMAN, ELLEN D (CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:D
Last Name:BLACKMAN
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 1:4750 BEDFORD AVE
Mailing Address - Street 2:1K
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2651
Mailing Address - Country:US
Mailing Address - Phone:917-692-7445
Mailing Address - Fax:
Practice Address - Street 1:4750 BEDFORD AVE
Practice Address - Street 2:1K
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2651
Practice Address - Country:US
Practice Address - Phone:917-692-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000661-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist