Provider Demographics
NPI:1881743235
Name:SULLIVAN, ELIZABETH MASCOLO (MA CCCSLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MASCOLO
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 ERIK DR
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-1745
Mailing Address - Country:US
Mailing Address - Phone:406-556-9853
Mailing Address - Fax:406-586-2732
Practice Address - Street 1:720 STONERIDGE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7032
Practice Address - Country:US
Practice Address - Phone:406-556-9853
Practice Address - Fax:406-586-2732
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSP984235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT660570OtherBLUE CROSS BLUE SHIELD
MT0532474Medicaid