Healthcare Provider Details

I. General information

NPI: 1861863268
Provider Name (Legal Business Name): STEFANIE M. ELLEDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BRIDGEPORT AVE
SHELTON CT
06484-4749
US

IV. Provider business mailing address

1931 BLACK ROCK TPKE ATTN: CREDENTIALING
FAIRFIELD CT
06825-3506
US

V. Phone/Fax

Practice location:
  • Phone: 203-922-1773
  • Fax: 203-924-2334
Mailing address:
  • Phone: 203-332-4363
  • Fax: 203-330-6761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number004988
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: