Provider Demographics
NPI:1669713376
Name:SULLIVAN, LILY NORA (MS CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:LILY
Middle Name:NORA
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 1:210 PORTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1588
Mailing Address - Country:US
Mailing Address - Phone:925-743-3322
Mailing Address - Fax:
Practice Address - Street 1:210 PORTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1588
Practice Address - Country:US
Practice Address - Phone:925-743-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 20522235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist