Provider Demographics
NPI:1720410475
Name:SULLIVAN, MARY (MFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4333 CORBETT DR # 1196
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-6111
Mailing Address - Country:US
Mailing Address - Phone:970-310-3406
Mailing Address - Fax:
Practice Address - Street 1:4333 CORBETT DR # 1196
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-6111
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILMFT-351106H00000X
COMFT.0001310106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist