Provider Demographics
NPI:1194081026
Name:ELLIS, GILLIAN MAE (SLP)
Entity type:Individual
Prefix:MISS
First Name:GILLIAN
Middle Name:MAE
Last Name:ELLIS
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 1:209 MAIN AVE S
Mailing Address - Street 2:SUITE 111
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-8139
Mailing Address - Country:US
Mailing Address - Phone:425-888-3347
Mailing Address - Fax:
Practice Address - Street 1:209 MAIN AVE S
Practice Address - Street 2:SUITE 111
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045-8139
Practice Address - Country:US
Practice Address - Phone:425-888-3347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60236341235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist