Provider Demographics
NPI:1649524778
Name:SULLIVAN, LAURIE LUCKER
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:LUCKER
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 1:4127 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3721
Mailing Address - Country:US
Mailing Address - Phone:618-334-3657
Mailing Address - Fax:
Practice Address - Street 1:801 N 11TH ST FL 2
Practice Address - Street 2:DEPT. OF SPECIAL EDUCATION
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1015
Practice Address - Country:US
Practice Address - Phone:314-633-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012029922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist