Provider Demographics
NPI:1033428461
Name:SULLIVAN, MELINDA BASKIN (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:BASKIN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:M
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1012 OCEANVIEW CT
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-2250
Mailing Address - Country:US
Mailing Address - Phone:904-557-1006
Mailing Address - Fax:
Practice Address - Street 1:910 S. 8TH STREET, SUITE 124
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-2250
Practice Address - Country:US
Practice Address - Phone:904-557-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10362101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12196399OtherCAQH
FL002775800Medicaid