Provider Demographics
NPI:1235940461
Name:SULLIVAN, TAYLEIGH MIRANDA (RBT-24-368486)
Entity type:Individual
Prefix:
First Name:TAYLEIGH
Middle Name:MIRANDA
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:RBT-24-368486
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S 4TH AVE LOT 35
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IN
Mailing Address - Zip Code:46938-1557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3549
Practice Address - Country:US
Practice Address - Phone:317-572-8793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-368486103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst