Provider Demographics
NPI:1235378407
Name:SULLIVAN, SHIRLEY (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
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 1:831 BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-8674
Mailing Address - Country:US
Mailing Address - Phone:630-681-1234
Mailing Address - Fax:
Practice Address - Street 1:831 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-8674
Practice Address - Country:US
Practice Address - Phone:630-681-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146001306235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist