Provider Demographics
NPI:1245362615
Name:SULLIVAN, ANTHONY MICHAEL (PSYD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
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 1:3225 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9380
Mailing Address - Country:US
Mailing Address - Phone:719-275-2351
Mailing Address - Fax:719-269-9386
Practice Address - Street 1:3225 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9380
Practice Address - Country:US
Practice Address - Phone:719-275-2351
Practice Address - Fax:719-269-9386
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2778101YP2500X
103T00000X
CO3490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26350246Medicaid