Provider Demographics
NPI:1760629075
Name:SULLIVAN, MAUREEN ANN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:MAUREEN
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:MAUREEN
Other - Middle Name:ANN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1714 WATSON CT
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4172
Mailing Address - Country:US
Mailing Address - Phone:575-640-5417
Mailing Address - Fax:
Practice Address - Street 1:1714 WATSON CT
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4172
Practice Address - Country:US
Practice Address - Phone:575-640-5417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16981235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist