Provider Demographics
NPI:1235137894
Name:SULLIVAN, MICHELLE LEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2305 N PARHAM RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-3156
Mailing Address - Country:US
Mailing Address - Phone:804-270-1124
Mailing Address - Fax:804-270-2090
Practice Address - Street 1:2305 N PARHAM RD
Practice Address - Street 2:SUITE 3
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-3156
Practice Address - Country:US
Practice Address - Phone:804-270-1124
Practice Address - Fax:804-270-2090
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004894103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP10766Medicare UPIN
PA040147LRRMedicare PIN