Provider Demographics
NPI:1346316106
Name:SULL, MARY LOU (PCC-S,LSW,LICDC)
Entity Type:Individual
Prefix:MRS
First Name:MARY LOU
Middle Name:
Last Name:SULL
Suffix:
Gender:F
Credentials:PCC-S,LSW,LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 MOLLAND DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-6415
Mailing Address - Country:US
Mailing Address - Phone:330-225-9415
Mailing Address - Fax:
Practice Address - Street 1:14843 W SPRAGUE RD STE A
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-1754
Practice Address - Country:US
Practice Address - Phone:440-234-9955
Practice Address - Fax:440-234-5994
Is Sole Proprietor?:No
Enumeration Date:2006-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0002000101Y00000X
OH991499101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)