Provider Demographics
NPI:1619215597
Name:SULLIVAN, BRENDAN G
Entity Type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:G
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 824
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-0824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1251 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-5154
Practice Address - Country:US
Practice Address - Phone:603-356-7294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist