Provider Demographics
NPI:1114105582
Name:SULLIVAN, BETTY H
Entity Type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:H
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 1:265 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-3511
Mailing Address - Country:US
Mailing Address - Phone:304-528-5175
Mailing Address - Fax:
Practice Address - Street 1:2850 5TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1436
Practice Address - Country:US
Practice Address - Phone:304-528-5000
Practice Address - Fax:304-528-5080
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0153119000Medicaid