Provider Demographics
NPI:1366703571
Name:SULLIVAN, JOANNA KATHLEEN (MS)
Entity type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:KATHLEEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 CRAGMONT ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-3007
Mailing Address - Country:US
Mailing Address - Phone:812-265-4788
Mailing Address - Fax:
Practice Address - Street 1:112 HOLT DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-3873
Practice Address - Country:US
Practice Address - Phone:812-265-8227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN332006235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist