Provider Demographics
NPI:1043364458
Name:ELLIS, COLETTE LEONIE (MED,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:COLETTE
Middle Name:LEONIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-7755
Mailing Address - Country:US
Mailing Address - Phone:405-921-2979
Mailing Address - Fax:
Practice Address - Street 1:1211 S 29TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-9651
Practice Address - Country:US
Practice Address - Phone:405-224-0002
Practice Address - Fax:405-224-0133
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist