Provider Demographics
NPI:1235385352
Name:SULLIVAN, MICHAEL J (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5754
Mailing Address - Country:US
Mailing Address - Phone:231-947-0350
Mailing Address - Fax:231-947-4311
Practice Address - Street 1:402 S UNION ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5754
Practice Address - Country:US
Practice Address - Phone:231-947-0350
Practice Address - Fax:231-947-4311
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101005085106H00000X
MI68010105271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist