Provider Demographics
NPI:1912073305
Name:SULLIVAN, MICHAEL JEROME
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEROME
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 1:4254 WINDING WAY
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-3171
Mailing Address - Country:US
Mailing Address - Phone:269-349-6090
Mailing Address - Fax:
Practice Address - Street 1:1312 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1205
Practice Address - Country:US
Practice Address - Phone:269-337-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010167821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical