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NPI Code Detail

MEDICARE: MRS. KELLI KATHARINA ELLENBAUM MS, CCC-SLP

MEDICARE: MRS. KELLI KATHARINA ELLENBAUM MS, CCC-SLP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1235Z00000XSpeech-Language Pathologist862ND

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
227424OTHERNDBCBS ND PROVIDER NUMBER
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1003934878
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELLI KATHARINA ELLENBAUM MS, CCC-SLP
Provider Business Mailing Address
First Line : 2625 N 19TH ST
Second Line :
City : BISMARCK
State : ND
Zip : 58503-0574
Country : US
Telephone Number : 701-222-3175
Fax Number : 701-222-3186
Provider Business Practice Location Address
First Line : 2625 N 19TH ST
Second Line :
City : BISMARCK
State : ND
Zip : 58503-0574
Country : US
Telephone Number : 701-222-3175
Fax Number : 701-222-3186
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/27/2007
Last Update Date : 03/15/2021

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Directions to “ MRS. KELLI KATHARINA ELLENBAUM MS, CCC-SLP” Practice Location

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