Provider Demographics
NPI:1487903159
Name:SULLIVAN COUNSELING
Entity type:Organization
Organization Name:SULLIVAN COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:260-451-2500
Mailing Address - Street 1:10311 DAWSONS CREEK BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1913
Mailing Address - Country:US
Mailing Address - Phone:260-451-2500
Mailing Address - Fax:260-451-2501
Practice Address - Street 1:10311 DAWSONS CREEK BLVD STE E
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1913
Practice Address - Country:US
Practice Address - Phone:260-451-2500
Practice Address - Fax:260-451-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001106A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150640HHHMedicare PIN