Provider Demographics
NPI:1871109520
Name:BENETTI, ELLEN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BENETTI
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 1:21338 EGRET PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-7030
Mailing Address - Country:US
Mailing Address - Phone:360-853-5002
Mailing Address - Fax:
Practice Address - Street 1:305 N 6TH ST
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-9825
Practice Address - Country:US
Practice Address - Phone:360-466-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA14285152OtherAMERICAN SPEECH LANGUAGE AND HEARING ASSOCIATION
WA6100253OtherWASHINGTON STATE DEPARTMENT OF HEALTH
WA546105HOtherEDUCATION CERTIFICATE