Provider Demographics
NPI:1467159897
Name:SULLIVAN, JUSTINE ELISE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ELISE
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 1:5404 104TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-4804
Mailing Address - Country:US
Mailing Address - Phone:253-363-5239
Mailing Address - Fax:
Practice Address - Street 1:7282 STINSON AVE STE B
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-4930
Practice Address - Country:US
Practice Address - Phone:253-858-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling