Provider Demographics
NPI:1417273269
Name:SULLIVAN, VIRGINIA (LCSW, LCADC)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:600 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1716
Practice Address - Country:US
Practice Address - Phone:502-639-3978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164999101Y00000X
KY2530881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor