Provider Demographics
NPI:1871764779
Name:SULLIVAN, GLENN R (PHD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 COLSTON PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-1812
Mailing Address - Country:US
Mailing Address - Phone:540-463-2080
Mailing Address - Fax:
Practice Address - Street 1:30 CROSSING LN STE 101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-6354
Practice Address - Country:US
Practice Address - Phone:540-463-2080
Practice Address - Fax:540-464-7648
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003867103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1103398805OtherUNITED HEALTHCARE
VA923366841OtherHEALTHKEEPERS
VA336-841OtherANTHEM
VASC0001096Medicaid