Provider Demographics
NPI:1023050168
Name:SULLIVAN, TERI RAE (PHD)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:RAE
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 1:7180 W 107TH ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-2523
Mailing Address - Country:US
Mailing Address - Phone:913-341-5700
Mailing Address - Fax:913-341-5750
Practice Address - Street 1:7180 W 107TH ST
Practice Address - Street 2:SUITE 20
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-2523
Practice Address - Country:US
Practice Address - Phone:913-341-5700
Practice Address - Fax:913-341-5750
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS0442103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSSUS71097Medicaid
KSSUS71097Medicaid
KS0002582Medicare PIN