Provider Demographics
NPI:1922469212
Name:SULLIVAN, REBECCA L (MS, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LM
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, NCC, LPC
Mailing Address - Street 1:66 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3032
Mailing Address - Country:US
Mailing Address - Phone:203-645-5563
Mailing Address - Fax:
Practice Address - Street 1:66 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3032
Practice Address - Country:US
Practice Address - Phone:203-645-5563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2994101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional