Provider Demographics
NPI:1073907697
Name:SULLIVAN, SALLY (LPC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 OFFICE PARK DR.
Mailing Address - Street 2:SUITE A
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655
Mailing Address - Country:US
Mailing Address - Phone:662-801-6940
Mailing Address - Fax:662-234-3535
Practice Address - Street 1:1202 OFFICE PARK DR.
Practice Address - Street 2:SUITE A
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-801-6940
Practice Address - Fax:662-234-3535
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1969101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional