Provider Demographics
NPI:1528184306
Name:SULLIVAN, BERNARD JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10540 MARTY ST STE 155
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-2654
Mailing Address - Country:US
Mailing Address - Phone:913-451-2843
Mailing Address - Fax:913-383-1088
Practice Address - Street 1:10540 MARTY ST STE 155
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-2654
Practice Address - Country:US
Practice Address - Phone:913-451-2843
Practice Address - Fax:913-383-1088
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP-0436103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS606084OtherBLUE CROSS PROVIDER
MO07571-01-0OtherBLUE CROSS PROVIDER #
MO07571-01-0OtherBLUE CROSS PROVIDER #