Healthcare Provider Details

I. General information

NPI: 1922475391
Provider Name (Legal Business Name): KATHRYN ELLSWORTH M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 WEYMOUTH DR SE
GRAND RAPIDS MI
49508-3763
US

IV. Provider business mailing address

4135 WEYMOUTH DR SE
GRAND RAPIDS MI
49508-3763
US

V. Phone/Fax

Practice location:
  • Phone: 616-443-1699
  • Fax:
Mailing address:
  • Phone: 616-443-1699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101004307
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: