Provider Demographics
NPI:1609672526
Name:SULLIVAN, ABIGAIL JADE
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:JADE
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 COUNTRY BROOK ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-7166
Mailing Address - Country:US
Mailing Address - Phone:812-343-9688
Mailing Address - Fax:
Practice Address - Street 1:8888 KEYSTONE CROSSING
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-4609
Practice Address - Country:US
Practice Address - Phone:463-842-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician