Provider Demographics
NPI:1205042850
Name:SULLIVAN, RENEE L (MFT)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MARCAR RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-5929
Mailing Address - Country:US
Mailing Address - Phone:478-718-1306
Mailing Address - Fax:
Practice Address - Street 1:153 MARCAR RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-5929
Practice Address - Country:US
Practice Address - Phone:478-718-1306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist