Provider Demographics
NPI:1477998938
Name:SULLIVAN, ANDY ELIAS (BS)
Entity Type:Individual
Prefix:MR
First Name:ANDY
Middle Name:ELIAS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4716
Mailing Address - Country:US
Mailing Address - Phone:217-398-8464
Mailing Address - Fax:
Practice Address - Street 1:401 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4716
Practice Address - Country:US
Practice Address - Phone:217-398-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker