Provider Demographics
NPI:1114243540
Name:SULLIVAN, MICHAEL CERVANTES
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CERVANTES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ELM ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-8401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 ELM ST
Practice Address - Street 2:SUITE 212
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-8401
Practice Address - Country:US
Practice Address - Phone:650-591-9623
Practice Address - Fax:650-591-9750
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist