Provider Demographics
NPI:1508265976
Name:SULLIVAN, DANIEL (PHD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8221
Mailing Address - Country:US
Mailing Address - Phone:314-251-4683
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-4683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025009596103G00000X
NY098032104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker