Provider Demographics
NPI:1407311640
Name:SULLIVAN, NATALIE JEAN (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:JEAN
Other - Last Name:SANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2665 BENT ELM LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-7140
Mailing Address - Country:US
Mailing Address - Phone:757-289-7670
Mailing Address - Fax:
Practice Address - Street 1:5405 BABCOCK ST NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5020
Practice Address - Country:US
Practice Address - Phone:321-722-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27904235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist