Provider Demographics
NPI:1124664461
Name:SULLIVAN, MICHELLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 WILKINS AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-7752
Mailing Address - Country:US
Mailing Address - Phone:209-499-7832
Mailing Address - Fax:
Practice Address - Street 1:4715 YOSEMITE BOULEVARD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95357
Practice Address - Country:US
Practice Address - Phone:209-574-9707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18889235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist