Provider Demographics
NPI:1053840975
Name:SULLIVAN, BRADEN ALEC (N/A)
Entity Type:Individual
Prefix:MR
First Name:BRADEN
Middle Name:ALEC
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 N OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2106
Mailing Address - Country:US
Mailing Address - Phone:316-558-3410
Mailing Address - Fax:316-267-5444
Practice Address - Street 1:2258 N LAKEWAY CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205
Practice Address - Country:US
Practice Address - Phone:316-945-7117
Practice Address - Fax:316-945-7447
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS385HR2060X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child