Healthcare Provider Details

I. General information

NPI: 1467023556
Provider Name (Legal Business Name): DR. CONOR MICHAEL SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 CLAYTON RD
SAINT LOUIS MO
63117-1002
US

IV. Provider business mailing address

8900 CLAYTON RD
SAINT LOUIS MO
63117-1002
US

V. Phone/Fax

Practice location:
  • Phone: 636-346-2328
  • Fax:
Mailing address:
  • Phone: 636-346-2328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2022033745
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: