Provider Demographics
NPI:1558806505
Name:SULLIVAN, VICTOR JR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
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 1:590 ELLIS RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3555
Mailing Address - Country:US
Mailing Address - Phone:904-800-2231
Mailing Address - Fax:904-800-2233
Practice Address - Street 1:590 ELLIS RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3555
Practice Address - Country:US
Practice Address - Phone:904-800-2231
Practice Address - Fax:904-800-2233
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)