Provider Demographics
NPI:1629714605
Name:SULLIVAN, MARY C (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 CROSSWICKS RD STE 4
Mailing Address - Street 2:
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505-2602
Mailing Address - Country:US
Mailing Address - Phone:609-372-4613
Mailing Address - Fax:609-372-4618
Practice Address - Street 1:231 CROSSWICKS RD STE 4
Practice Address - Street 2:
Practice Address - City:BORDENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08505-2602
Practice Address - Country:US
Practice Address - Phone:609-372-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00015200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist