Provider Demographics
NPI:1679392096
Name:SULLIVAN, MICHAEL J (RBT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21105 KIMES LN
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-9604
Mailing Address - Country:US
Mailing Address - Phone:808-852-8005
Mailing Address - Fax:
Practice Address - Street 1:21105 KIMES LN
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-9604
Practice Address - Country:US
Practice Address - Phone:808-852-8005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-21-7343-292140106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician