Provider Demographics
NPI:1437205747
Name:SULLIVAN, MARK SCOTT (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SCOTT
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6360 JACKSON RD
Mailing Address - Street 2:SUITE M
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9597
Mailing Address - Country:US
Mailing Address - Phone:734-930-0031
Mailing Address - Fax:734-930-0083
Practice Address - Street 1:6360 JACKSON RD
Practice Address - Street 2:SUITE M
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9597
Practice Address - Country:US
Practice Address - Phone:734-930-0031
Practice Address - Fax:734-930-0083
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist