Provider Demographics
NPI:1861248023
Name:SULLIVAN, SKYLER MADISON
Entity type:Individual
Prefix:
First Name:SKYLER
Middle Name:MADISON
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 1:2868 MAHAN DR UNIT 25
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2868 MAHAN DR UNIT 25
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5468
Practice Address - Country:US
Practice Address - Phone:850-391-6060
Practice Address - Fax:850-692-6206
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-24-71632103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst