Provider Demographics
NPI:1417376708
Name:SULLIVAN, SOFIA BAGLIVO (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SOFIA
Middle Name:BAGLIVO
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:SOFIA
Other - Middle Name:ANNA
Other - Last Name:BAGLIVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:206 YORK ST APT 1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-3645
Mailing Address - Country:US
Mailing Address - Phone:215-512-1792
Mailing Address - Fax:
Practice Address - Street 1:206 YORK ST APT 1
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3645
Practice Address - Country:US
Practice Address - Phone:215-512-1792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NY024595235Z00000X
NJ41YS01058600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04174021Medicaid