Provider Demographics
NPI:1568867877
Name:SULLIVAN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34918 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-3981
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14105 SNOW RD
Practice Address - Street 2:
Practice Address - City:BROOKPARK
Practice Address - State:OH
Practice Address - Zip Code:44142-2557
Practice Address - Country:US
Practice Address - Phone:216-676-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-7193235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist