Provider Demographics
NPI:1326282633
Name:SULLIVAN, BERNARD HARRELL JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:HARRELL
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N HOFFMAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-1525
Mailing Address - Country:US
Mailing Address - Phone:704-813-4033
Mailing Address - Fax:
Practice Address - Street 1:203 N HOFFMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1525
Practice Address - Country:US
Practice Address - Phone:704-813-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102806103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1817WOtherBCBS NC
NC6001164Medicaid
NC1817WOtherBCBS NC