Provider Demographics
NPI:1811475585
Name:SULLIVAN, DOMINIQUE LAMERE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LAMERE
Last Name:SULLIVAN
Suffix:
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 1:6342 STONEGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-2152
Mailing Address - Country:US
Mailing Address - Phone:810-399-3609
Mailing Address - Fax:
Practice Address - Street 1:2284 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-3446
Practice Address - Country:US
Practice Address - Phone:810-221-7871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician