Provider Demographics
NPI:1215267554
Name:SULLIVAN, MARY J (SLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SKOWHEGAN RD
Mailing Address - Street 2:MAINE CENTER FOR INTEGRATED REHAB
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-3303
Mailing Address - Country:US
Mailing Address - Phone:207-453-1330
Mailing Address - Fax:
Practice Address - Street 1:95 SKOWHEGAN RD
Practice Address - Street 2:MAINE CENTER FOR INTEGRATED REHAB
Practice Address - City:FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04937-3303
Practice Address - Country:US
Practice Address - Phone:207-453-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1885235Z00000X
MASP7845SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433215399Medicaid