Provider Demographics
NPI:1881962702
Name:SULLIVAN, WHITNEY AUSTIN
Entity type:Individual
Prefix:MS
First Name:WHITNEY
Middle Name:AUSTIN
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 1:9565 HWY 78 BLDG 700 SUITE 102
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-3938
Mailing Address - Country:US
Mailing Address - Phone:888-510-6369
Mailing Address - Fax:888-510-5362
Practice Address - Street 1:930 FOLLY RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412
Practice Address - Country:US
Practice Address - Phone:843-314-5434
Practice Address - Fax:843-277-6237
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5243235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6269Medicaid
SCSA1359Medicaid