Provider Demographics
NPI:1407028079
Name:O'SULLIVAN, MARY ELIZABETH (MA CCCA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:MA CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 N BROADWAY
Mailing Address - Street 2:SUITE400
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1318
Mailing Address - Country:US
Mailing Address - Phone:914-963-8588
Mailing Address - Fax:914-963-0253
Practice Address - Street 1:984 N BROADWAY
Practice Address - Street 2:SUITE400
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1318
Practice Address - Country:US
Practice Address - Phone:914-963-8588
Practice Address - Fax:914-963-0253
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001837-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400001412Medicare PIN