Provider Demographics
NPI:1497923023
Name:SULLIVAN, BRIAN KENNETH (PSYD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KENNETH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MATHIS FERRY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-2988
Mailing Address - Country:US
Mailing Address - Phone:843-971-5171
Mailing Address - Fax:843-971-5178
Practice Address - Street 1:250 MATHIS FERRY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-2988
Practice Address - Country:US
Practice Address - Phone:843-971-5171
Practice Address - Fax:843-971-5178
Is Sole Proprietor?:No
Enumeration Date:2008-02-17
Last Update Date:2008-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical