| Doctor Name: | DR. JEREMY RAY SULLIVAN |
| NPI Number: | 1043441306 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PSY.D |
| License Number: | 04800000878 |
| Business Practice Address: | 655 Main St Bennington, VT - 052012870 |
| Business Phone Number: | 4133476679 |
| Business Fax Number: | |
| Mailing Address: | 342 Lesure Rd, STAMFORD |
| State: | VT |
| Postal Code: | 053529569 |
| Phone Number: | 8026941994 |
| Fax Number: | |
| NPI Enumeration Date: | 08/05/2009 |
| NPI Last Update Date: | 08/05/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 04800000878 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VT |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |