Healthcare Provider Details

I. General information

NPI: 1538103643
Provider Name (Legal Business Name): ELIZABETH GRAL SULLIVAN MS/CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 NORTH PORT WASHINGTON ROAD
MEQUON WI
53097
US

IV. Provider business mailing address

816 E HYDE WAY
FOX POINT WI
53217-3221
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-7444
  • Fax:
Mailing address:
  • Phone: 414-352-6817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number878-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: