Provider Demographics
NPI:1093349672
Name:SULLIVAN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:1000 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4739
Mailing Address - Country:US
Mailing Address - Phone:401-533-9100
Mailing Address - Fax:401-533-9105
Practice Address - Street 1:1000 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4739
Practice Address - Country:US
Practice Address - Phone:401-533-9100
Practice Address - Fax:401-533-9105
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP00631-P235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISB870OtherBC RI
RI0614OtherNHP RI
RIES01788Medicaid