Provider Demographics
NPI:1457686545
Name:SULLIVAN, JOHN ALOYSIUS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALOYSIUS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:SEAN
Other - Middle Name:A
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 225066
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-5066
Mailing Address - Country:US
Mailing Address - Phone:415-335-7542
Mailing Address - Fax:
Practice Address - Street 1:10 FUNSTON AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94129-1109
Practice Address - Country:US
Practice Address - Phone:415-335-7542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23067103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACY254ZMedicare PIN