Provider Demographics
NPI:1194833004
Name:SULLIVAN, ROBERT (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BARBARA LOOP SE
Mailing Address - Street 2:STE I
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1088
Mailing Address - Country:US
Mailing Address - Phone:505-450-7799
Mailing Address - Fax:
Practice Address - Street 1:1400 BARBARA LOOP SE
Practice Address - Street 2:STE I
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1088
Practice Address - Country:US
Practice Address - Phone:505-450-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1452106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist