Provider Demographics
NPI:1275218364
Name:SULLIVAN, MISSY (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:MISSY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 HIGHWOODS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2051
Mailing Address - Country:US
Mailing Address - Phone:336-272-0855
Mailing Address - Fax:
Practice Address - Street 1:1501 HIGHWOODS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2051
Practice Address - Country:US
Practice Address - Phone:336-272-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP019094101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health