Healthcare Provider Details

I. General information

NPI: 1689939951
Provider Name (Legal Business Name): SULLIVAN & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 W SUGAR CREEK RD
CHARLOTTE NC
28269-7314
US

IV. Provider business mailing address

3225 W SUGAR CREEK RD
CHARLOTTE NC
28269-7314
US

V. Phone/Fax

Practice location:
  • Phone: 704-813-4033
  • Fax:
Mailing address:
  • Phone: 704-813-4033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNC

VIII. Authorized Official

Name: DR. BERNARD SULLIVAN
Title or Position: OWNER
Credential: PHD
Phone: 877-306-3748