Provider Demographics
NPI:1417703612
Name:ELLAM, RYLIE E
Entity type:Individual
Prefix:
First Name:RYLIE
Middle Name:E
Last Name:ELLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1841
Mailing Address - Country:US
Mailing Address - Phone:617-265-1134
Mailing Address - Fax:
Practice Address - Street 1:30 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1841
Practice Address - Country:US
Practice Address - Phone:617-265-1134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist