Provider Demographics
NPI:1275757460
Name:SULLIVAN, DOLORES ARLT (SLP)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:ARLT
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3327
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-3327
Mailing Address - Country:US
Mailing Address - Phone:505-863-8887
Mailing Address - Fax:928-871-2837
Practice Address - Street 1:1 MI N OF 264 MUSTANG ROAD
Practice Address - Street 2:
Practice Address - City:ST. MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511-0100
Practice Address - Country:US
Practice Address - Phone:928-871-2822
Practice Address - Fax:928-871-2837
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ921280Medicaid
AZAZ0308030OtherBLUE CROSS BLUE SHIELD