Provider Demographics
NPI:1710006325
Name:SULLIVAN, BRYAN E (LPC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4003
Mailing Address - Country:US
Mailing Address - Phone:704-370-3235
Mailing Address - Fax:704-370-3377
Practice Address - Street 1:1123 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4003
Practice Address - Country:US
Practice Address - Phone:704-370-3235
Practice Address - Fax:704-370-3377
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPC3531101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102012Medicaid
NCE0997OtherMEDCOST
NC1378COtherBLUECROSS BLUESHIELD
NC358073OtherMHN