Provider Demographics
NPI:1144256934
Name:SULLIVAN, JOHN PETER (PSYD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PETER
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 PARK AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-6030
Mailing Address - Country:US
Mailing Address - Phone:408-296-7721
Mailing Address - Fax:
Practice Address - Street 1:2797 PARK AVE STE 207
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-6063
Practice Address - Country:US
Practice Address - Phone:408-286-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16164103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL161640Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER