Provider Demographics
NPI:1205146065
Name:SULLIVAN-WITMER, DEBORAH J (CCC-SPLP)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:J
Last Name:SULLIVAN-WITMER
Suffix:
Gender:F
Credentials:CCC-SPLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MINOA
Mailing Address - State:NY
Mailing Address - Zip Code:13116-1520
Mailing Address - Country:US
Mailing Address - Phone:315-656-7906
Mailing Address - Fax:
Practice Address - Street 1:128 ELM ST
Practice Address - Street 2:
Practice Address - City:MINOA
Practice Address - State:NY
Practice Address - Zip Code:13116-1520
Practice Address - Country:US
Practice Address - Phone:315-656-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004274-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY004274-1OtherLICENSE SPEECH/LANGUAGE PATHOLOGY
01018729OtherCERTIFICATE OF CLINICAL COMPETENCE