Provider Demographics
NPI:1427791615
Name:SULLIVAN, DANIEL JAMES
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
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 1:388 GARDEN AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8999
Mailing Address - Country:US
Mailing Address - Phone:815-685-8562
Mailing Address - Fax:
Practice Address - Street 1:388 GARDEN AVE STE 110
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8999
Practice Address - Country:US
Practice Address - Phone:616-222-0631
Practice Address - Fax:616-222-0631
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851104339101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor