Kelli Katharina Ellenbaum, MS, CCC-SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

862 Issued in ND

Practice address

2625 N 19TH St
Bismarck, ND 58503-0574

Phone

(701) 222-3175

Fax

(701) 222-3186

NPI assigned

Mar 27, 2007

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in ND

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Science

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Red Door Pediatric Therapy, Inc

  • Speech-Language Pathologist
  • Bismarck, ND
  • NPI 1639257033
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174953600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1615766400000",
    "number": "1003934878",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2625 N 19TH ST",
            "city": "BISMARCK",
            "state": "ND",
            "postal_code": "585030574",
            "telephone_number": "701-222-3175",
            "fax_number": "701-222-3186"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2625 N 19TH ST",
            "city": "BISMARCK",
            "state": "ND",
            "postal_code": "585030574",
            "telephone_number": "701-222-3175",
            "fax_number": "701-222-3186"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLENBAUM",
        "first_name": "KELLI",
        "middle_name": "KATHARINA",
        "name_prefix": "Mrs.",
        "credential": "MS, CCC-SLP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-03-27",
        "last_updated": "2021-03-15",
        "certification_date": "2021-03-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "ND",
            "license": "862",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1454835",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS ND PROVIDER NUMBER",
            "identifier": "27424",
            "state": "ND"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "54627",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Elite Eye Care PLLC
• Jody Gayle Elkin
• Candace J Ell
• Melissa Ell
• Samantha Ell
• Nathan Glenn Ellingson
• Megan Elliott
• Chantalle Ellis, MA, LPCC
• Wesley Ellison
• Mohanad A Elshiekh

• Speech-Language Pathologist in Bismarck, ND
• Providers in Bismarck, ND by specialty
• Speech-Language Pathologist in North Dakota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 15, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.