Provider Demographics
NPI:1497065213
Name:SULLIVAN, STACY (MA,CCC/LSP)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA,CCC/LSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 JACKSON CRES
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1054
Mailing Address - Country:US
Mailing Address - Phone:631-424-8972
Mailing Address - Fax:
Practice Address - Street 1:235 JACKSON CRESCENT
Practice Address - Street 2:
Practice Address - City:CENTERPORT
Practice Address - State:NY
Practice Address - Zip Code:11721
Practice Address - Country:US
Practice Address - Phone:631-424-8972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0065631235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist