Provider Demographics
NPI:1164053500
Name:SULLIVAN, DENNIQUA
Entity Type:Individual
Prefix:
First Name:DENNIQUA
Middle Name:
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 1:48952 ROSEGARDEN CT
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-8034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1603A S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6261
Practice Address - Country:US
Practice Address - Phone:246-840-8842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician