Provider Demographics
NPI:1306110176
Name:SULLIVAN, TIMOTHY COLEMAN (MED, BCBA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:COLEMAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 DAVID DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-1767
Mailing Address - Country:US
Mailing Address - Phone:774-313-0981
Mailing Address - Fax:
Practice Address - Street 1:7291 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4211
Practice Address - Country:US
Practice Address - Phone:949-939-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-26
Last Update Date:2012-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-9321103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst