Provider Demographics
NPI:1538399399
Name:SULLIVAN, LOTTIE J (LISW-S)
Entity type:Individual
Prefix:MRS
First Name:LOTTIE
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:LOTTIE
Other - Middle Name:J
Other - Last Name:CONNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:4488 W. BROAD ST. SUITE A
Mailing Address - Street 2:COUNSELING LTD.
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-5610
Mailing Address - Country:US
Mailing Address - Phone:614-870-6670
Mailing Address - Fax:614-870-6855
Practice Address - Street 1:7467 EAST MAIN ST. SUITE 1
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7270
Practice Address - Country:US
Practice Address - Phone:614-552-3979
Practice Address - Fax:614-870-6855
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0900135SUPV1041C0700X
OHI09001351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicaid