Provider Demographics
NPI:1154530749
Name:SULLIVAN, JUDY CAROL (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:CAROL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 BLANDING ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2907
Mailing Address - Country:US
Mailing Address - Phone:803-252-9444
Mailing Address - Fax:803-748-9220
Practice Address - Street 1:1528 BLANDING ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2907
Practice Address - Country:US
Practice Address - Phone:803-252-9444
Practice Address - Fax:803-748-9220
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC310103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical