Healthcare Provider Details

I. General information

NPI: 1053840975
Provider Name (Legal Business Name): BRADEN ALEC SULLIVAN N/A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2258 N LAKEWAY CIR
WICHITA KS
67205
US

IV. Provider business mailing address

3223 N OLIVER ST
WICHITA KS
67220-2106
US

V. Phone/Fax

Practice location:
  • Phone: 316-945-7117
  • Fax: 316-945-7447
Mailing address:
  • Phone: 316-558-3410
  • Fax: 316-267-5444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: