MEDICARE: DEREK NICHOLAS SULLIVAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1790597540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK NICHOLAS SULLIVAN

Provider Business Mailing Address
First Line	:	3240 HILLCREST LN
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36109-3538
Country	:	US
Telephone Number	:	334-414-3066
Fax Number	:

Provider Business Practice Location Address
First Line	:	3966 ATLANTA HWY STE 375
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36109-2919
Country	:	US
Telephone Number	:	334-414-3066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2025
Last Update Date	:	01/20/2025

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