Provider Demographics
NPI:1386894574
Name:FULLWOOD, ELLEN-BETH (MS CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:ELLEN-BETH
Middle Name:
Last Name:FULLWOOD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15114 CLOVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8308
Mailing Address - Country:US
Mailing Address - Phone:239-410-2629
Mailing Address - Fax:309-410-2629
Practice Address - Street 1:15114 CLOVERDALE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8308
Practice Address - Country:US
Practice Address - Phone:239-410-2629
Practice Address - Fax:309-410-2629
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9064235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist