Provider Demographics
NPI:1588866677
Name:SULLIVAN, KERI A
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 ELM ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02333-1003
Mailing Address - Country:US
Mailing Address - Phone:774-259-7934
Mailing Address - Fax:
Practice Address - Street 1:60 QUAKER HWY
Practice Address - Street 2:
Practice Address - City:UXBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01569-1628
Practice Address - Country:US
Practice Address - Phone:508-278-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASP0192OtherBCBS