Provider Demographics
NPI:1215585542
Name:SULLIVAN, TIMOTHY W
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 STATE AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3984
Mailing Address - Country:US
Mailing Address - Phone:360-943-0780
Mailing Address - Fax:
Practice Address - Street 1:711 STATE AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-3984
Practice Address - Country:US
Practice Address - Phone:360-943-0780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WA171M00000X
WACG61302453101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty