Provider Demographics
NPI:1174865687
Name:SULLIVAN, AMBER KAY (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:KAY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13428 MOUNT TABOR RD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-7444
Mailing Address - Country:US
Mailing Address - Phone:816-230-0026
Mailing Address - Fax:
Practice Address - Street 1:13428 MOUNT TABOR RD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-7444
Practice Address - Country:US
Practice Address - Phone:816-230-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000167733235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist