Provider Demographics
NPI:1003324104
Name:SULLIVAN, MEAGAN (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 E MUIRWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7639
Mailing Address - Country:US
Mailing Address - Phone:480-610-6981
Mailing Address - Fax:480-898-7419
Practice Address - Street 1:2487 S GILBERT RD STE 106-153
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8899
Practice Address - Country:US
Practice Address - Phone:480-744-5286
Practice Address - Fax:480-675-4538
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-20-41371103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst