Provider Demographics
NPI:1538103643
Name:SULLIVAN, ELIZABETH GRAL (MS/CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:GRAL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 E HYDE WAY
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3221
Mailing Address - Country:US
Mailing Address - Phone:414-352-6817
Mailing Address - Fax:
Practice Address - Street 1:13111 NORTH PORT WASHINGTON ROAD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097
Practice Address - Country:US
Practice Address - Phone:262-243-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI878-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist