Provider Demographics
NPI:1093886236
Name:SULLIVAN, BRYCE FREDERICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:FREDERICK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 N KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1137
Mailing Address - Country:US
Mailing Address - Phone:618-659-8787
Mailing Address - Fax:
Practice Address - Street 1:910 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1116
Practice Address - Country:US
Practice Address - Phone:618-659-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000159809103TC0700X
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
691275OtherHEALTHLINK HMO & PPO
IL06032019OtherBCBS PPO