Provider Demographics
NPI:1194407064
Name:SULLIVAN, BRON DAVID
Entity type:Individual
Prefix:
First Name:BRON
Middle Name:DAVID
Last Name:SULLIVAN
Suffix:
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 1:4460 W SHAW AVE # 595
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6210
Mailing Address - Country:US
Mailing Address - Phone:559-277-3494
Mailing Address - Fax:559-271-8927
Practice Address - Street 1:2142 N BLYTHE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-5402
Practice Address - Country:US
Practice Address - Phone:559-276-7680
Practice Address - Fax:559-271-8927
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker