Provider Demographics
NPI:1720394562
Name:SULLIVAN-TIBBS, MICHAEL A (LCSW, LCAC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:SULLIVAN-TIBBS
Suffix:
Gender:M
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-1392
Mailing Address - Country:US
Mailing Address - Phone:615-225-4729
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:317-748-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000061A101YA0400X
IN34005914A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)