Provider Demographics
NPI:1639416977
Name:SULLIVAN, LORETHA (COUNSELOR)
Entity Type:Individual
Prefix:
First Name:LORETHA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 NW 115TH ST
Mailing Address - Street 2:2513 N.W.115TH STREET
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-6608
Mailing Address - Country:US
Mailing Address - Phone:405-206-5459
Mailing Address - Fax:
Practice Address - Street 1:2513 NW 115TH ST
Practice Address - Street 2:2513 N,W. 115TH STREET
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6608
Practice Address - Country:US
Practice Address - Phone:405-206-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional