Provider Demographics
NPI:1114394202
Name:SULLIVAN, SHANNON (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-1244
Mailing Address - Country:US
Mailing Address - Phone:774-318-1900
Mailing Address - Fax:774-272-8810
Practice Address - Street 1:64 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1244
Practice Address - Country:US
Practice Address - Phone:774-318-1900
Practice Address - Fax:774-272-8810
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist