Provider Demographics
NPI:1861517476
Name:SHIRLEY, ELLEN (MACCCSLP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 S VAN HOOSE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-9107
Mailing Address - Country:US
Mailing Address - Phone:479-442-9259
Mailing Address - Fax:
Practice Address - Street 1:2474 E JOYCE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4932
Practice Address - Country:US
Practice Address - Phone:479-521-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR676235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist