Provider Demographics
NPI:1366474165
Name:SULLIVAN, MARY JANE (AUD)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 LOCKE RD.
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 LIBRARY WAY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NH
Practice Address - Zip Code:03824
Practice Address - Country:US
Practice Address - Phone:603-862-5077
Practice Address - Fax:603-862-4511
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHA449231H00000X
MA299231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30431497Medicaid