Provider Demographics
NPI:1205260635
Name:SULLIVAN, RYAN JAMES
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
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 1:11600 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-6506
Mailing Address - Country:US
Mailing Address - Phone:818-686-3179
Mailing Address - Fax:
Practice Address - Street 1:11600 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-6506
Practice Address - Country:US
Practice Address - Phone:818-686-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF82837106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist