Provider Demographics
NPI:1255828307
Name:SULLIVAN, STEPHANIE MARIE (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CUMBERLAND CROSSING DRIVE
Mailing Address - Street 2:PMB 175
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383
Mailing Address - Country:US
Mailing Address - Phone:248-821-4899
Mailing Address - Fax:
Practice Address - Street 1:2710 DOUBLE EAGLE LN APT N
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2863
Practice Address - Country:US
Practice Address - Phone:248-821-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-15
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101007160106H00000X
IN35002289A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist