Healthcare Provider Details

I. General information

NPI: 1164756839
Provider Name (Legal Business Name): SULLIVAN PSYCHIATRIC SVCS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 ALLGOOD RD
STONE MOUNTAIN GA
30083-6145
US

IV. Provider business mailing address

425 ALLGOOD RD
STONE MOUNTAIN GA
30083-6145
US

V. Phone/Fax

Practice location:
  • Phone: 404-508-3822
  • Fax: 404-508-3823
Mailing address:
  • Phone: 404-508-3822
  • Fax: 404-508-3823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number047162
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier343324511A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: RAINA SULLIVAN
Title or Position: OWNER
Credential: MD
Phone: 404-508-3822