Provider Demographics
NPI:1710552328
Name:SUTHERLAND, ELYSE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CLAY BANK RD APT C3
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-2502
Mailing Address - Country:US
Mailing Address - Phone:302-490-8145
Mailing Address - Fax:
Practice Address - Street 1:710 ROHNERT PARK EXPY E
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-1514
Practice Address - Country:US
Practice Address - Phone:925-338-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30591235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty