Provider Demographics
NPI:1720044084
Name:SULLIVAN, DIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:DIAN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BROADWAY
Mailing Address - Street 2:SUITE 315
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2149
Mailing Address - Country:US
Mailing Address - Phone:260-489-6030
Mailing Address - Fax:260-489-5536
Practice Address - Street 1:800 BROADWAY
Practice Address - Street 2:SUITE 315
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2149
Practice Address - Country:US
Practice Address - Phone:260-489-6030
Practice Address - Fax:260-489-5536
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001106A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
INR94245Medicare UPIN
IN150640HHHMedicare PIN
IN220780AMedicare PIN