1417227968 NPI number — DR. MICHELLE SULLIVAN-GAST PSY.D.

Table of content: DR. MICHELLE SULLIVAN-GAST PSY.D. (NPI 1417227968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417227968 NPI number — DR. MICHELLE SULLIVAN-GAST PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN-GAST
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SULLIVAN
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417227968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3040 WILLIAMS DR
Provider Second Line Business Mailing Address:
SUITE 402
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-4618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-573-3573
Provider Business Mailing Address Fax Number:
703-573-3574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3040 WILLIAMS DR
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22031-4618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-573-3573
Provider Business Practice Location Address Fax Number:
703-573-3574
Provider Enumeration Date:
12/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  0810004489 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com