Provider Demographics
NPI:1427171214
Name:SULLIVAN, SUSAN EMMA
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:EMMA
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:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:BONDVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61815-0133
Mailing Address - Country:US
Mailing Address - Phone:217-863-2051
Mailing Address - Fax:
Practice Address - Street 1:210 SOUTH MARKET
Practice Address - Street 2:
Practice Address - City:BONDVILLE
Practice Address - State:IL
Practice Address - Zip Code:61815-0133
Practice Address - Country:US
Practice Address - Phone:217-863-2051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist