Provider Demographics
NPI:1316678980
Name:SULLIVAN, AMBER (SLP)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
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 1:5703 GULF TECH DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8238
Mailing Address - Country:US
Mailing Address - Phone:228-875-5447
Mailing Address - Fax:228-875-5448
Practice Address - Street 1:8905 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4421
Practice Address - Country:US
Practice Address - Phone:228-215-0521
Practice Address - Fax:228-215-0619
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS-4830235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist