Provider Demographics
NPI:1205201688
Name:SULLIVAN, PETER JOSHUA (LMSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOSHUA
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N SAGE ST
Mailing Address - Street 2:APT 5
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-4065
Mailing Address - Country:US
Mailing Address - Phone:773-297-7236
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-7314
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010960041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical