Provider Demographics
NPI:1942740881
Name:ELLISTON, KHALIAH YVONNE
Entity type:Individual
Prefix:
First Name:KHALIAH
Middle Name:YVONNE
Last Name:ELLISTON
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 1:6111 S DREXEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-2627
Mailing Address - Country:US
Mailing Address - Phone:773-297-1023
Mailing Address - Fax:
Practice Address - Street 1:1629 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4504
Practice Address - Country:US
Practice Address - Phone:773-297-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-25
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0044002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer