Provider Demographics
NPI:1790033264
Name:SULLIVAN, CAITLIN COLLEEN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:CAITLIN
Middle Name:COLLEEN
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 1:144 E 128TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-1329
Mailing Address - Country:US
Mailing Address - Phone:917-521-3803
Mailing Address - Fax:
Practice Address - Street 1:4360 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-2409
Practice Address - Country:US
Practice Address - Phone:917-521-3803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021627-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist