Provider Demographics
NPI:1962548487
Name:MIJARES, EILEEN SULLIVAN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:SULLIVAN
Last Name:MIJARES
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3042 CARLOW CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-3303
Mailing Address - Country:US
Mailing Address - Phone:305-968-1312
Mailing Address - Fax:
Practice Address - Street 1:3042 CARLOW CIR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-3303
Practice Address - Country:US
Practice Address - Phone:305-968-1312
Practice Address - Fax:850-807-5114
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889101000Medicaid
FLSA7115OtherFL DEPT OF HEALTH LIC