Provider Demographics
NPI:1114531738
Name:SULLIVAN, TRACY LYNN (LCPC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 5TH AVE E # UNITLB14
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5321
Mailing Address - Country:US
Mailing Address - Phone:406-351-6334
Mailing Address - Fax:406-300-0426
Practice Address - Street 1:723 5TH AVE E # UNITLB14
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5321
Practice Address - Country:US
Practice Address - Phone:406-351-6334
Practice Address - Fax:406-300-0426
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-18990101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health