Individual
MRS. KELLI KATHARINA ELLENBAUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS, CCC-SLP
Contact information
Practice address
2625 N 19TH ST, BISMARCK, ND 58503-0574
(701) 222-3175
(701) 222-3186
Mailing address
2625 N 19TH ST, BISMARCK, ND 58503-0574
(701) 222-3175
(701) 222-3186
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
862
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1454835
—
ND
01
—
27424
BCBS ND PROVIDER NUMBER
ND
05
—
54627
—
ND
Enumeration date
03/27/2007
Last updated
03/15/2021
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