Provider Demographics
NPI:1992921662
Name:SULLIVAN, GERALD MICHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-5341
Mailing Address - Country:US
Mailing Address - Phone:847-392-5948
Mailing Address - Fax:847-577-9952
Practice Address - Street 1:228 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-8107
Practice Address - Country:US
Practice Address - Phone:224-659-2708
Practice Address - Fax:847-577-9952
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical