Provider Demographics
NPI:1679766307
Name:GLINDA SULLIVAN, PSYD
Entity Type:Organization
Organization Name:GLINDA SULLIVAN, PSYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLINDA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:573-528-7569
Mailing Address - Street 1:1400 STATE ROAD F
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583
Mailing Address - Country:US
Mailing Address - Phone:573-528-7569
Mailing Address - Fax:573-774-4009
Practice Address - Street 1:1400 STATE ROAD F
Practice Address - Street 2:SUITE 101
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583
Practice Address - Country:US
Practice Address - Phone:573-528-7569
Practice Address - Fax:573-774-4009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024741103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty