Healthcare Provider Details

I. General information

NPI: 1174871370
Provider Name (Legal Business Name): CHRISTOPHER SULLIVAN PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2012
Last Update Date: 11/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10293 N MERIDIAN ST STE 210
INDIANAPOLIS IN
46290-1079
US

IV. Provider business mailing address

10293 N MERIDIAN ST STE 210
INDIANAPOLIS IN
46290-1079
US

V. Phone/Fax

Practice location:
  • Phone: 317-581-2292
  • Fax: 317-581-2285
Mailing address:
  • Phone: 317-581-2292
  • Fax: 317-581-2285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number20041471A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041471A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042520A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042125A
License Number StateIN

VIII. Authorized Official

Name: DR. CHRISTOPHER SULLIVAN
Title or Position: OWNER
Credential: PHD
Phone: 317-581-2292