Provider Demographics
NPI:1558827980
Name:SULLIVAN, ROBIN LEE (LADC, PLMHP)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:LEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LADC, PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13110 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1732
Mailing Address - Country:US
Mailing Address - Phone:402-686-6947
Mailing Address - Fax:
Practice Address - Street 1:4102 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1851
Practice Address - Country:US
Practice Address - Phone:402-444-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11634101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health