Provider Demographics
NPI:1346767118
Name:SULLIVAN, MELISSA JANE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
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 1:920 HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1874
Mailing Address - Country:US
Mailing Address - Phone:313-510-6381
Mailing Address - Fax:
Practice Address - Street 1:44444 MOUND RD STE 610
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314
Practice Address - Country:US
Practice Address - Phone:586-307-4757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006208235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist