Provider Demographics
NPI:1598123267
Name:SULLIVAN, CHELSEA (BCBA)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3363
Mailing Address - Country:US
Mailing Address - Phone:850-855-8635
Mailing Address - Fax:
Practice Address - Street 1:301 PERKINS DR STE B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3248
Practice Address - Country:US
Practice Address - Phone:575-652-3155
Practice Address - Fax:575-652-4104
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-13-14316103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57229279Medicaid