Provider Demographics
NPI:1053946327
Name:RIELLY, ELLEN KATE (SLP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:KATE
Last Name:RIELLY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:KATE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:302 W 79TH ST APT 8B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6117
Mailing Address - Country:US
Mailing Address - Phone:516-993-7924
Mailing Address - Fax:
Practice Address - Street 1:1110 2ND AVE RM 302
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2021
Practice Address - Country:US
Practice Address - Phone:212-842-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-07
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029825235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist