Provider Demographics
NPI:1891091906
Name:SULLIVAN, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
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:PO BOX 28220
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592-8220
Mailing Address - Country:US
Mailing Address - Phone:505-471-5006
Mailing Address - Fax:505-820-9220
Practice Address - Street 1:501 S 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435-2417
Practice Address - Country:US
Practice Address - Phone:575-472-0745
Practice Address - Fax:575-472-0746
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor