Provider Demographics
NPI:1699823088
Name:SULLIVAN, JAMES H (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:H
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 PROSPECT ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5399
Mailing Address - Country:US
Mailing Address - Phone:360-876-2322
Mailing Address - Fax:360-874-0477
Practice Address - Street 1:700 PROSPECT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5399
Practice Address - Country:US
Practice Address - Phone:360-876-2322
Practice Address - Fax:360-874-0477
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000906103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical