Provider Demographics
NPI:1275024697
Name:SULLIVAN, DAVID LYNN (LADC PLMHP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LADC PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2742 S 39TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-3234
Mailing Address - Country:US
Mailing Address - Phone:402-202-9342
Mailing Address - Fax:
Practice Address - Street 1:1620 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1563
Practice Address - Country:US
Practice Address - Phone:402-202-9342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11360101YM0800X
NE1252101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty