Provider Demographics
NPI:1316755994
Name:SULLIVAN, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5316 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-3912
Mailing Address - Country:US
Mailing Address - Phone:406-750-8214
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VAUGHN
Practice Address - State:MT
Practice Address - Zip Code:59487-9716
Practice Address - Country:US
Practice Address - Phone:406-750-8214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health