Provider Demographics
NPI:1023120730
Name:SULLIVAN, MICHELLE K (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:K
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 1:347 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-2135
Mailing Address - Country:US
Mailing Address - Phone:607-654-0062
Mailing Address - Fax:
Practice Address - Street 1:3769 NY-417
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:NY
Practice Address - Zip Code:14855
Practice Address - Country:US
Practice Address - Phone:607-792-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8194235Z00000X
NY012816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8911096 00Medicaid