MEDICARE: AMY WATSON SULLIVAN M.S., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	110705	TX

General Provider Information

NPI Number	:	1164915435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY WATSON SULLIVAN M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	3620 BELLAIRE DR N
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-2115
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7217 HAWKINS VIEW DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3927
Country	:	US
Telephone Number	:	817-479-7019
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2018
Last Update Date	:	04/23/2021

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Directions to “ AMY WATSON SULLIVAN M.S., CCC-SLP” Practice Location

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