Provider Demographics
NPI:1538576764
Name:SULLIVAN, JOHN MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10145 SQUIRES WAY
Mailing Address - Street 2:
Mailing Address - City:TOANO
Mailing Address - State:VA
Mailing Address - Zip Code:23168-9541
Mailing Address - Country:US
Mailing Address - Phone:757-566-2238
Mailing Address - Fax:
Practice Address - Street 1:ONE OLD OYSTER POINT ROAD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602
Practice Address - Country:US
Practice Address - Phone:757-969-6848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004303103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist