Provider Demographics
NPI:1871697110
Name:SULLIVAN, EVELYN R (PHD)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2653 SW 87TH DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-9313
Mailing Address - Country:US
Mailing Address - Phone:352-331-0020
Mailing Address - Fax:352-331-0022
Practice Address - Street 1:2653 SW 87TH DR
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-9313
Practice Address - Country:US
Practice Address - Phone:352-331-0020
Practice Address - Fax:352-331-0022
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0005750103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
54357OtherBCBS FL
54357AMedicare ID - Type Unspecified