1679766307 NPI number — GLINDA SULLIVAN, PSYD

Table of content: (NPI 1679766307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679766307 NPI number — GLINDA SULLIVAN, PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLINDA SULLIVAN, PSYD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679766307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 STATE ROAD F
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WAYNESVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-528-7569
Provider Business Mailing Address Fax Number:
573-774-4009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 STATE ROAD F
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WAYNESVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-528-7569
Provider Business Practice Location Address Fax Number:
573-774-4009
Provider Enumeration Date:
08/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
GLINDA
Authorized Official Middle Name:
MAE
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
573-528-7569

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2004024741 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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