Provider Demographics
NPI:1558958561
Name:SUBASIC-SULLIVAN, HANA (MA,LMFT)
Entity Type:Individual
Prefix:
First Name:HANA
Middle Name:
Last Name:SUBASIC-SULLIVAN
Suffix:
Gender:F
Credentials:MA,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 COUNTY ROAD B W STE 202
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4053
Mailing Address - Country:US
Mailing Address - Phone:651-300-1112
Mailing Address - Fax:
Practice Address - Street 1:1611 COUNTY ROAD B W STE 202
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4053
Practice Address - Country:US
Practice Address - Phone:651-300-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3864106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist