Provider Demographics
NPI:1467142406
Name:SULLIVAN, RACHEL RENAY
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:RENAY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2029
Mailing Address - Country:US
Mailing Address - Phone:256-503-8586
Mailing Address - Fax:
Practice Address - Street 1:290 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2029
Practice Address - Country:US
Practice Address - Phone:256-503-8586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL563101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health