Provider Demographics
NPI:1043441306
Name:SULLIVAN, JEREMY RAY (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:RAY
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247-2828
Mailing Address - Country:US
Mailing Address - Phone:413-347-6679
Mailing Address - Fax:
Practice Address - Street 1:77 HOSPITAL AVE STE 214
Practice Address - Street 2:
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247-2538
Practice Address - Country:US
Practice Address - Phone:413-398-5064
Practice Address - Fax:413-398-5496
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04800000878103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical