Provider Demographics
NPI:1497488001
Name:SULLIVAN, RICHARD JOHN JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 ENCINAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2178
Mailing Address - Country:US
Mailing Address - Phone:831-469-1700
Mailing Address - Fax:831-425-1905
Practice Address - Street 1:380 ENCINAL ST STE 200
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2178
Practice Address - Country:US
Practice Address - Phone:831-469-1700
Practice Address - Fax:831-425-1905
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 172V00000X
CA14953101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker