MEDICARE: MR. MATTHEW BURTON SULLIVAN MS 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	SA7753	FL

General Provider Information

NPI Number	:	1437279320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW BURTON SULLIVAN MS CCC SLP

Provider Business Mailing Address
First Line	:	5601 35TH AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33710-1911
Country	:	US
Telephone Number	:	727-347-1292
Fax Number	:	727-347-1292

Provider Business Practice Location Address
First Line	:	5601 35TH AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33710-1911
Country	:	US
Telephone Number	:	727-347-1292
Fax Number	:	727-347-1292

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

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/08/2007

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