Provider Demographics
NPI:1679164610
Name:SULLIVAN, EDIE GAYLE (MSCCC-SLP)
Entity type:Individual
Prefix:
First Name:EDIE
Middle Name:GAYLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6202
Mailing Address - Country:US
Mailing Address - Phone:603-472-3755
Mailing Address - Fax:
Practice Address - Street 1:103 COUNTY RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6202
Practice Address - Country:US
Practice Address - Phone:603-472-3755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0781235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty