Provider Demographics
NPI:1770275869
Name:ANTHONY M SULLIVAN PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:ANTHONY M SULLIVAN PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:719-275-5185
Mailing Address - Street 1:608 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4910
Mailing Address - Country:US
Mailing Address - Phone:719-275-5185
Mailing Address - Fax:
Practice Address - Street 1:608 S 9TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4910
Practice Address - Country:US
Practice Address - Phone:719-275-5185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty