Provider Demographics
NPI:1255673398
Name:TYSON SULLIVAN, BRENDA J
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:TYSON SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11816 GWENDOLYN LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73131-4402
Mailing Address - Country:US
Mailing Address - Phone:405-315-1939
Mailing Address - Fax:
Practice Address - Street 1:11816 GWENDOLYN LN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-4402
Practice Address - Country:US
Practice Address - Phone:405-315-1939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health