Provider Demographics
NPI:1770654386
Name:SULLIVAN, MARY K (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
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 1:700 WEST AVE S
Mailing Address - Street 2:PHYSICIAN SERVICES DEPT
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4783
Mailing Address - Country:US
Mailing Address - Phone:608-392-4156
Mailing Address - Fax:608-392-4156
Practice Address - Street 1:212 11TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4116
Practice Address - Country:US
Practice Address - Phone:608-392-9555
Practice Address - Fax:608-392-9432
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3331101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional