Healthcare Provider Details

I. General information

NPI: 1912822917
Provider Name (Legal Business Name): MR. ROBERT KENNETH SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 I 75 BUSINESS SPUR
SAULT SAINTE MARIE MI
49783-3536
US

IV. Provider business mailing address

1708 MERIDIAN ST APT B14
SAULT SAINTE MARIE MI
49783-2672
US

V. Phone/Fax

Practice location:
  • Phone: 800-645-4737
  • Fax:
Mailing address:
  • Phone: 906-748-2308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: