Healthcare Provider Details

I. General information

NPI: 1891005492
Provider Name (Legal Business Name): GLENDA SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 S. MORNINGSIDE DR
GOODYEAR AZ
85338
US

IV. Provider business mailing address

10710 S. MORNINGSIDE DR
GOODYEAR AZ
85338
US

V. Phone/Fax

Practice location:
  • Phone: 623-932-2429
  • Fax:
Mailing address:
  • Phone: 623-932-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number2576526
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: