Provider Demographics
NPI:1629507413
Name:SULLIVAN, MAGGIE
Entity Type:Individual
Prefix:
First Name:MAGGIE
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 1:5879 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:IL
Mailing Address - Zip Code:62501-7578
Mailing Address - Country:US
Mailing Address - Phone:217-520-5442
Mailing Address - Fax:
Practice Address - Street 1:1095 N. MERIDIAN ROAD
Practice Address - Street 2:
Practice Address - City:HARRISTOWN
Practice Address - State:IL
Practice Address - Zip Code:62537
Practice Address - Country:US
Practice Address - Phone:217-963-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013726235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1629507413Medicaid