Provider Demographics
NPI:1598822538
Name:SULLIVAN, PATRICIA A (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:PATTY
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:2475 VILLAGE DR STE 107
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6729
Mailing Address - Country:US
Mailing Address - Phone:912-729-2294
Mailing Address - Fax:912-673-9457
Practice Address - Street 1:2475 VILLAGE DR STE 107
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6729
Practice Address - Country:US
Practice Address - Phone:912-729-2294
Practice Address - Fax:912-673-9457
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005458235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA341003OtherWELLCARE PROVIDER NUMBER
GA10059131OtherAMERIGROUP PROVIDER NUMBE