Provider Demographics
NPI:1174021364
Name:SULLIVAN, ELIZABETH (MA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7508 NEW LAGRANGE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222
Mailing Address - Country:US
Mailing Address - Phone:502-709-9427
Mailing Address - Fax:
Practice Address - Street 1:7508 NEW LAGRANGE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-709-9427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy