Provider Demographics
NPI:1790391928
Name:SULLIVAN, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SULLIVAN
Suffix:
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 1:7110 63RD PL NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-8938
Mailing Address - Country:US
Mailing Address - Phone:206-747-7790
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician