Healthcare Provider Details

I. General information

NPI: 1194485284
Provider Name (Legal Business Name): MADELINE ANNE ELLIOTT CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 NORTERRE CIR
LIBERTY MO
64068-3412
US

IV. Provider business mailing address

534 RICHFIELD RD APT B
LIBERTY MO
64068-2540
US

V. Phone/Fax

Practice location:
  • Phone: 816-479-4793
  • Fax:
Mailing address:
  • Phone: 573-470-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2017023558
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: