Provider Demographics
NPI:1124600697
Name:SULLIVAN, MIRANDA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4614
Mailing Address - Country:US
Mailing Address - Phone:208-249-4890
Mailing Address - Fax:
Practice Address - Street 1:449 S FITNESS PL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6828
Practice Address - Country:US
Practice Address - Phone:208-957-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist