Provider Demographics
NPI:1013356724
Name:SULLIVAN, CASSIDY E
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:E
Last Name:SULLIVAN
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 1:31741 RANCHO VIEJO RD
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-6722
Mailing Address - Country:US
Mailing Address - Phone:949-613-9910
Mailing Address - Fax:
Practice Address - Street 1:31741 RANCHO VIEJO RD
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-6722
Practice Address - Country:US
Practice Address - Phone:949-613-9910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20437235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist