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General NPI Number Information
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NPI Number | 1023549284
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Entity Type | Individual
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Provider Name | ELLEN LIVERSIDGE M.S., CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 03/21/2017
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Last Update Date | 03/21/2017
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Provider Practice Location Address
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Address Line | HWY 64, OLD HIGH SCHOOL RD.
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City | SHIPROCK
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State | NM
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Zip | 87420
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Country | US
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Telephone | 505-368-4984
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Fax |
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Provider Business Mailing Address
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Address Line | 4923 DEL MONTE AVE
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City | SAN DIEGO
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State | CA
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Zip | 92107-3208
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Country | US
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Telephone | 301-775-3649
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 5271
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License Number State | NM
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