Provider Demographics
NPI:1396916706
Name:POURASEF, ELLY E (AUD, CCC/A)
Entity type:Individual
Prefix:DR
First Name:ELLY
Middle Name:E
Last Name:POURASEF
Suffix:
Gender:F
Credentials:AUD, CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9071 SOUTH 1300 WEST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088
Mailing Address - Country:US
Mailing Address - Phone:801-938-1117
Mailing Address - Fax:801-938-2771
Practice Address - Street 1:908 TOWN AND COUNTRY BLVD.
Practice Address - Street 2:SUITE 120
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2208
Practice Address - Country:US
Practice Address - Phone:713-984-7562
Practice Address - Fax:866-961-3161
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80074231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K5766Medicare PIN