Provider Demographics
NPI:1790231207
Name:SULLIVAN, GARY HODGES (LPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:HODGES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BLUE RIDGE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4431
Mailing Address - Country:US
Mailing Address - Phone:706-946-5607
Mailing Address - Fax:706-374-7628
Practice Address - Street 1:153 SCHOOL DR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-0313
Practice Address - Country:US
Practice Address - Phone:706-973-3215
Practice Address - Fax:706-973-3216
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008887101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional