Basic Information
| Provider Information | |||||||||
| NPI: | 1598123267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | CHELSEA | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 511 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325783363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508558635 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 PERKINS DR STE B | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756523155 | ||||||||
| FaxNumber: | 5756524104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 02/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-13-14316 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 57229279 | 05 | NM | MEDICAID |