Provider Demographics
NPI:1598915571
Name:O'SULLIVAN, MARY ELIZABETH (AUDIOLOGIST)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-3352
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:501 SE 172ND AVE
Practice Address - Street 2:230
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9542
Practice Address - Country:US
Practice Address - Phone:360-397-3920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23141231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR243537Medicaid
OR243537Medicaid