Provider Demographics
NPI:1316254600
Name:SULLIVAN, MARY ANN
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
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 1:15 BELVEDERE LN
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-6100
Mailing Address - Country:US
Mailing Address - Phone:843-705-3390
Mailing Address - Fax:
Practice Address - Street 1:300 WOODHAVEN DR
Practice Address - Street 2:SEABROOK
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-7511
Practice Address - Country:US
Practice Address - Phone:843-842-3747
Practice Address - Fax:843-842-3739
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2857235Z00000X
GA001866235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist