Provider Demographics
NPI:1962260612
Name:SULLIVAN, MICHAEL TRAVIS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TRAVIS
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 1:4061 INDIAN CREEK PKWY STE 330
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-4030
Mailing Address - Country:US
Mailing Address - Phone:913-444-6868
Mailing Address - Fax:
Practice Address - Street 1:4061 INDIAN CREEK PKWY STE 330
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-4030
Practice Address - Country:US
Practice Address - Phone:913-444-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04627-T101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional