Provider Demographics
NPI:1013041276
Name:SULLIVAN, CHERIE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:CHERIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2521
Mailing Address - Country:US
Mailing Address - Phone:850-769-5371
Mailing Address - Fax:850-872-9558
Practice Address - Street 1:927 GRACE AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2521
Practice Address - Country:US
Practice Address - Phone:850-769-5371
Practice Address - Fax:850-872-9558
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 995235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014763900Medicaid