Healthcare Provider Details

I. General information

NPI: 1790877561
Provider Name (Legal Business Name): RODNEY ANTHONY SULLIVAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 REDBUSH CT SUITE 2
JOHNSON CITY TN
37601-4340
US

IV. Provider business mailing address

2 REDBUSH CT SUITE 2
JOHNSON CITY TN
37601-4340
US

V. Phone/Fax

Practice location:
  • Phone: 423-952-0992
  • Fax:
Mailing address:
  • Phone: 423-952-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberP0000001569
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: