Provider Demographics
NPI:1841947132
Name:SULLIVAN, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
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 1:770 SAYBROOK RD UNIT B4
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4739
Mailing Address - Country:US
Mailing Address - Phone:860-421-4052
Mailing Address - Fax:860-421-4053
Practice Address - Street 1:770 SAYBROOK RD UNIT B4
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4739
Practice Address - Country:US
Practice Address - Phone:860-421-4052
Practice Address - Fax:860-421-4053
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1950103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician