Provider Demographics
NPI:1417227968
Name:SULLIVAN-GAST, MICHELLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:SULLIVAN-GAST
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3040 WILLIAMS DR
Mailing Address - Street 2:SUITE 402
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:703-573-3573
Mailing Address - Fax:703-573-3574
Practice Address - Street 1:3040 WILLIAMS DR
Practice Address - Street 2:SUITE 402
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4618
Practice Address - Country:US
Practice Address - Phone:703-573-3573
Practice Address - Fax:703-573-3574
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004489103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical