Healthcare Provider Details

I. General information

NPI: 1033717749
Provider Name (Legal Business Name): SULLIVAN MCCALLON FRIEDRICH M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SULLIVAN LYN MCCALLON

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94-1181 KA UKA BLVD STE C
WAIPAHU HI
96797-4485
US

IV. Provider business mailing address

103 N SPRINGVIEW DR
ENTERPRISE AL
36330-5064
US

V. Phone/Fax

Practice location:
  • Phone: 808-260-9056
  • Fax:
Mailing address:
  • Phone: 270-873-9557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP011270
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-2306
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: