Provider Demographics
NPI:1508836537
Name:SULLIVAN, BRUCE WAYNE (LPC)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:WAYNE
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E PASS RD
Mailing Address - Street 2:STE. 3
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3212
Mailing Address - Country:US
Mailing Address - Phone:228-604-0099
Mailing Address - Fax:228-604-2001
Practice Address - Street 1:450 E PASS RD
Practice Address - Street 2:STE. 3
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3212
Practice Address - Country:US
Practice Address - Phone:228-604-0099
Practice Address - Fax:228-604-2001
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0727101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSLPCOtherMENTAL HEALTH