Provider Demographics
NPI:1902404023
Name:SULLIVAN, SARA LYNN
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:LYNN
Other - Last Name:CAMPOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-1238
Mailing Address - Country:US
Mailing Address - Phone:260-416-2216
Mailing Address - Fax:
Practice Address - Street 1:3320 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1918
Practice Address - Country:US
Practice Address - Phone:260-483-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004287A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist