Provider Demographics
NPI:1023268356
Name:ELLIS, TAMMY ALLEEN (CCC-A)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:ALLEEN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SAINT VINCENTS DR
Mailing Address - Street 2:POB#3 SUITE 402
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1606
Mailing Address - Country:US
Mailing Address - Phone:205-933-9236
Mailing Address - Fax:205-933-9213
Practice Address - Street 1:3400 HIGHWAY 78 E
Practice Address - Street 2:205 MEDICAL ARTS TOWER
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8907
Practice Address - Country:US
Practice Address - Phone:205-221-4630
Practice Address - Fax:205-221-4731
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0768A237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51598737OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL113797Medicaid
AL113797Medicaid