Provider Demographics
NPI:1104955350
Name:SULLIVAN, JULIE (LCPC)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:ANNE
Other - Last Name:HIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:165 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2406
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1044
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME254250099Medicaid