Provider Demographics
NPI:1437279320
Name:SULLIVAN, MATTHEW BURTON (MS CCC SLP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BURTON
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5601 35TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1911
Mailing Address - Country:US
Mailing Address - Phone:727-347-1292
Mailing Address - Fax:727-347-1292
Practice Address - Street 1:5601 35TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1911
Practice Address - Country:US
Practice Address - Phone:727-347-1292
Practice Address - Fax:727-347-1292
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7753235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist