Provider Demographics
NPI:1669966966
Name:SULLIVAN, DAVID LEE JR
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:SULLIVAN
Suffix:JR
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 1:513 CANNONS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3645
Mailing Address - Country:US
Mailing Address - Phone:502-403-6886
Mailing Address - Fax:
Practice Address - Street 1:513 CANNONS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3645
Practice Address - Country:US
Practice Address - Phone:502-403-6886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator