Provider Demographics
NPI:1508437245
Name:SULLIVAN, COLLEEN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:SULLIVAN
Other - Last Name:BALASH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:84 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-4450
Mailing Address - Country:US
Mailing Address - Phone:203-563-9360
Mailing Address - Fax:
Practice Address - Street 1:84 DANBURY RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4450
Practice Address - Country:US
Practice Address - Phone:203-563-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTBA.001168103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst