Provider Demographics
NPI:1992006621
Name:SULLIVAN, MANDY JO (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:JO
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:353 S LEWIS LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3441
Mailing Address - Country:US
Mailing Address - Phone:708-625-1339
Mailing Address - Fax:
Practice Address - Street 1:20 N 13TH ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2057
Practice Address - Country:US
Practice Address - Phone:618-687-2378
Practice Address - Fax:618-687-2733
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-10-7895103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1-10-7895Medicaid