Provider Demographics
NPI:1275839102
Name:SULLIVAN, HEATHER MAUREEN (L AC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MAUREEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 N RIVERSIDE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5919
Mailing Address - Country:US
Mailing Address - Phone:224-440-7373
Mailing Address - Fax:847-543-1512
Practice Address - Street 1:495 N RIVERSIDE DR STE 104
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5919
Practice Address - Country:US
Practice Address - Phone:224-440-7373
Practice Address - Fax:847-543-1512
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000967171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist