Provider Demographics
NPI:1710218003
Name:SULLIVAN, MICHELE L (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7216 S SEVEN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-9531
Mailing Address - Country:US
Mailing Address - Phone:503-680-2497
Mailing Address - Fax:
Practice Address - Street 1:7216 S SEVEN OAKS LN
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-9531
Practice Address - Country:US
Practice Address - Phone:503-680-2497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17056171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator