Provider Demographics
NPI:1104933472
Name:O SULLIVAN, EVANGELINE (PHD)
Entity type:Individual
Prefix:DR
First Name:EVANGELINE
Middle Name:
Last Name:O SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JEANNIE
Other - Middle Name:
Other - Last Name:O SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1901 NW MILITARY HWY STE 112
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213
Mailing Address - Country:US
Mailing Address - Phone:210-828-0950
Mailing Address - Fax:210-828-0206
Practice Address - Street 1:1901 NW MILITARY HWY STE 112
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213
Practice Address - Country:US
Practice Address - Phone:210-828-0950
Practice Address - Fax:210-828-0206
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11418101Y00000X, 101YM0800X, 101YP2500X
TX003395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist