Provider Demographics
NPI:1760126619
Name:SULLIVAN, TINA J (LPC)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4633
Mailing Address - Country:US
Mailing Address - Phone:662-251-3245
Mailing Address - Fax:
Practice Address - Street 1:609 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4633
Practice Address - Country:US
Practice Address - Phone:662-251-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 101Y00000X
MS3015101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional