Provider Demographics
NPI:1770341109
Name:SULLIVAN, COLLEEN REBEKAH
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:REBEKAH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 S 8TH ST APT 3N
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-2848
Mailing Address - Country:US
Mailing Address - Phone:928-899-2598
Mailing Address - Fax:
Practice Address - Street 1:736 S 8TH ST APT 3N
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-2848
Practice Address - Country:US
Practice Address - Phone:928-899-2598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist