Provider Demographics
NPI:1063791747
Name:SULLIVAN, MICHAEL GRUER (LMHC, MCAP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRUER
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMHC, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 GRANBY ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6015
Mailing Address - Country:US
Mailing Address - Phone:863-838-9437
Mailing Address - Fax:
Practice Address - Street 1:2024 N. CRYSTAL LAKE DR.
Practice Address - Street 2:SUITE 200 ROOM 205
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-6015
Practice Address - Country:US
Practice Address - Phone:863-410-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15284101Y00000X, 101YA0400X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional