Provider Demographics
NPI:1679609911
Name:SULLIVAN, ROBERT DENNIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DENNIS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:DENNIS
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3183 JACKSON HEIGHTS ST
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5782
Mailing Address - Country:US
Mailing Address - Phone:907-225-5576
Mailing Address - Fax:206-299-4244
Practice Address - Street 1:102 CARLANNA LAKE ROAD
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901
Practice Address - Country:US
Practice Address - Phone:907-225-5576
Practice Address - Fax:206-299-4244
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK605101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor