Provider Demographics
NPI:1235469180
Name:SULLIVAN, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 SE JOHNSON AVE
Mailing Address - Street 2:#138
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-5001
Mailing Address - Country:US
Mailing Address - Phone:772-349-1871
Mailing Address - Fax:
Practice Address - Street 1:1970 MICHIGAN AVE
Practice Address - Street 2:BLDG. C-1
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-5758
Practice Address - Country:US
Practice Address - Phone:321-209-1871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8490103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist