Provider Demographics
NPI:1205055076
Name:SULLIVAN, THERESA PAULETTE (AUD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:PAULETTE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 PINE RD
Mailing Address - Street 2:
Mailing Address - City:COPAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12516-1109
Mailing Address - Country:US
Mailing Address - Phone:518-329-5761
Mailing Address - Fax:
Practice Address - Street 1:250 TUYTENBRIDGE RD
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5429
Practice Address - Country:US
Practice Address - Phone:845-336-7235
Practice Address - Fax:845-336-4726
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001487231H00000X
NY001886235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00473001Medicaid
NYB18708Medicare UPIN
NYW03821Medicare ID - Type Unspecified