Provider Demographics
NPI:1548886294
Name:ELLENBAUM, RYAN (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ELLENBAUM
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-4743
Mailing Address - Country:US
Mailing Address - Phone:215-870-4976
Mailing Address - Fax:
Practice Address - Street 1:822 MONTGOMERY AVE STE 306
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-1948
Practice Address - Country:US
Practice Address - Phone:215-220-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL015132235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist