Provider Demographics
NPI:1871022418
Name:SULLIVAN, RYAN DANIEL (LPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DANIEL
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 1:480 VISION WAY
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-9376
Mailing Address - Country:US
Mailing Address - Phone:207-451-8540
Mailing Address - Fax:
Practice Address - Street 1:480 VISION WAY
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122
Practice Address - Country:US
Practice Address - Phone:207-451-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6139101YM0800X
COLPC.0014024101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health