Provider Demographics
NPI:1679042436
Name:SULLIVAN, BREANNA (LCSW, LAC)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10390 JEFFERSON HWY APT 246
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-7246
Mailing Address - Country:US
Mailing Address - Phone:225-505-0792
Mailing Address - Fax:
Practice Address - Street 1:624 CONNELL PARK LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6534
Practice Address - Country:US
Practice Address - Phone:225-300-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA128071041C0700X
LA1620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)