Provider Demographics
NPI:1053190025
Name:SULLIVAN, DONALD RAYMOND JR
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:RAYMOND
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2284 RIVER PARK CIR APT 1034
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4852
Mailing Address - Country:US
Mailing Address - Phone:516-479-4042
Mailing Address - Fax:
Practice Address - Street 1:5959 LAKE ELLENOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4633
Practice Address - Country:US
Practice Address - Phone:407-749-6568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician