Healthcare Provider Details

I. General information

NPI: 1801903000
Provider Name (Legal Business Name): CYNTHIA LUCK SULLIVAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CYNTHIA LUCK D'ARMAND

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 HAMAKER CT STE 103
FAIRFAX VA
22031-2220
US

IV. Provider business mailing address

3338 CONQUISTADOR CT
ANNANDALE VA
22003-1116
US

V. Phone/Fax

Practice location:
  • Phone: 703-876-0966
  • Fax:
Mailing address:
  • Phone: 703-851-7109
  • Fax: 202-745-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810002968
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: