Provider Demographics
NPI:1184295610
Name:SULLIVAN, KATHERINE TILLEY
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:TILLEY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LORDS HWY
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-1619
Mailing Address - Country:US
Mailing Address - Phone:203-917-7392
Mailing Address - Fax:
Practice Address - Street 1:440 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-1902
Practice Address - Country:US
Practice Address - Phone:860-893-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4124235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist