Provider Demographics
NPI:1073980116
Name:SULLIVAN, ANGELA CHRISTINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:CHRISTINE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:CHRISTINE
Other - Last Name:ARTERBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:124 CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2724
Mailing Address - Country:US
Mailing Address - Phone:503-358-8182
Mailing Address - Fax:
Practice Address - Street 1:124 CHANNEL DR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2724
Practice Address - Country:US
Practice Address - Phone:503-358-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60428847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALL60428847Medicaid