Provider Demographics
NPI:1780090753
Name:SULLIVAN, MICHELLE R (MED)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 S 31ST DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6949
Mailing Address - Country:US
Mailing Address - Phone:928-388-4301
Mailing Address - Fax:
Practice Address - Street 1:2573 S ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7336
Practice Address - Country:US
Practice Address - Phone:928-376-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10032101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)