Provider Demographics
NPI:1437661329
Name:SULLIVAN, ROBERTA J (JD, MA)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:JD, MA
Other - Prefix:MRS
Other - First Name:ROBIE
Other - Middle Name:J
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JD, MA
Mailing Address - Street 1:9022 N HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64157-8515
Mailing Address - Country:US
Mailing Address - Phone:816-809-5873
Mailing Address - Fax:
Practice Address - Street 1:9 VICTORY DR STE 3
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3807
Practice Address - Country:US
Practice Address - Phone:816-268-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015034336101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty