Provider Demographics
NPI:1407078983
Name:SULLIVAN, MARY JO (LADC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JO
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PINE TREE LN
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-5012
Mailing Address - Country:US
Mailing Address - Phone:405-321-8966
Mailing Address - Fax:
Practice Address - Street 1:125 PINE TREE LN
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-5012
Practice Address - Country:US
Practice Address - Phone:405-321-8966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK174101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)