Provider Demographics
NPI:1508191388
Name:SULLIVAN, MICHAEL JOSEPH (AUD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6813 MORGAN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2113
Mailing Address - Country:US
Mailing Address - Phone:612-861-8921
Mailing Address - Fax:
Practice Address - Street 1:6644 PENN AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2026
Practice Address - Country:US
Practice Address - Phone:612-293-7816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8481231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist