Provider Demographics
NPI:1619142312
Name:SULLIVAN, BRIAN J (MS LPC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6717 STONE GLEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562
Mailing Address - Country:US
Mailing Address - Phone:608-827-7100
Mailing Address - Fax:608-827-7101
Practice Address - Street 1:6717 STONE GLEN DRIVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562
Practice Address - Country:US
Practice Address - Phone:608-827-7100
Practice Address - Fax:608-827-7101
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31551251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39782800Medicaid