Provider Demographics
NPI:1750164786
Name:SULLIVAN, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
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 1:700 N SCHOENBECK RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60070-1231
Mailing Address - Country:US
Mailing Address - Phone:847-870-5206
Mailing Address - Fax:
Practice Address - Street 1:700 N SCHOENBECK RD
Practice Address - Street 2:
Practice Address - City:PROSPECT HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60070-1231
Practice Address - Country:US
Practice Address - Phone:847-870-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010394235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist