Provider Demographics
NPI:1831321991
Name:SULLIVAN, KELLY EILEEN (MS CCC - SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EILEEN
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 1:18512 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-4515
Mailing Address - Country:US
Mailing Address - Phone:310-371-8555
Mailing Address - Fax:
Practice Address - Street 1:18512 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504-4515
Practice Address - Country:US
Practice Address - Phone:310-371-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16875235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist