Provider Demographics
NPI:1225895238
Name:SULLIVAN, DAKOTA LEE (SUD)
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:LEE
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1814
Mailing Address - Country:US
Mailing Address - Phone:650-613-9055
Mailing Address - Fax:
Practice Address - Street 1:2251 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1814
Practice Address - Country:US
Practice Address - Phone:650-513-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)