Provider Demographics
NPI:1437822939
Name:BRUNKHORST, ELLISON
Entity type:Individual
Prefix:
First Name:ELLISON
Middle Name:
Last Name:BRUNKHORST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27491 HIGHWAY CC
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:MO
Mailing Address - Zip Code:64020-6409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 W ASHLEY RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2162
Practice Address - Country:US
Practice Address - Phone:660-882-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist