Provider Demographics
NPI:1528626009
Name:ELLISON, THOMAS DOUGLAS (MA, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:DOUGLAS
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MA, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 BENNETT AVE APT 7G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-2485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5030 BROADWAY STE 809
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1666
Practice Address - Country:US
Practice Address - Phone:212-304-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027539235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist