Provider Demographics
NPI:1174871370
Name:CHRISTOPHER SULLIVAN PHD PC
Entity type:Organization
Organization Name:CHRISTOPHER SULLIVAN PHD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-581-2292
Mailing Address - Street 1:10293 N MERIDIAN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1079
Mailing Address - Country:US
Mailing Address - Phone:317-581-2292
Mailing Address - Fax:317-581-2285
Practice Address - Street 1:10293 N MERIDIAN ST STE 210
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1079
Practice Address - Country:US
Practice Address - Phone:317-581-2292
Practice Address - Fax:317-581-2285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041471A103TC0700X, 103G00000X
IN20042520A103TC0700X
IN20042125A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty