Provider Demographics
NPI:1821603374
Name:SULLIVAN, VERONICA HELEN
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:HELEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 FAIRWAY LN APT 2
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5955
Mailing Address - Country:US
Mailing Address - Phone:435-757-6798
Mailing Address - Fax:
Practice Address - Street 1:90 E 200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4034
Practice Address - Country:US
Practice Address - Phone:435-752-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT12096842-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator