Provider Demographics
NPI:1033723374
Name:SULLIVAN, MARIAH M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 KING DR
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-9388
Mailing Address - Country:US
Mailing Address - Phone:541-974-3349
Mailing Address - Fax:
Practice Address - Street 1:1215 W LEWIS ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5472
Practice Address - Country:US
Practice Address - Phone:509-543-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61087668235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist