Provider Demographics
NPI:1194366070
Name:SULLIVAN, SEAN ALYSTON (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:ALYSTON
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 CORDOVA ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2745
Mailing Address - Country:US
Mailing Address - Phone:907-887-1045
Mailing Address - Fax:
Practice Address - Street 1:2600 CORDOVA ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2745
Practice Address - Country:US
Practice Address - Phone:907-279-9640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1194366070101YA0400X
AK171M00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1194366070Medicaid