Provider Demographics
NPI:1184826521
Name:SULLIVAN, THERESA MARIE (BA/QMHA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:BA/QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 MARCOLA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7948
Mailing Address - Country:US
Mailing Address - Phone:541-726-1465
Mailing Address - Fax:
Practice Address - Street 1:3995 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7948
Practice Address - Country:US
Practice Address - Phone:541-726-1465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator