Provider Demographics
NPI:1306260203
Name:MCCAFFERTY, ELLEN RAE (MA CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:RAE
Last Name:MCCAFFERTY
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-3007
Mailing Address - Country:US
Mailing Address - Phone:216-544-2829
Mailing Address - Fax:
Practice Address - Street 1:1215 W CLIFTON BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-1008
Practice Address - Country:US
Practice Address - Phone:216-227-5826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP4183235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-6001631Medicaid