Provider Demographics
NPI:1922622042
Name:SULLIVAN, ALEXANDER BLAKE (LCSW, LICSW, LIMHP)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:BLAKE
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LCSW, LICSW, LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2786 FAIRVIEW AVE N STE 38
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1306
Mailing Address - Country:US
Mailing Address - Phone:763-412-1993
Mailing Address - Fax:
Practice Address - Street 1:2786 FAIRVIEW AVE N STE 38
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1306
Practice Address - Country:US
Practice Address - Phone:763-412-1993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW166391041C0700X
UT13344228-35011041C0700X
COCSW.099291921041C0700X
AZ218541041C0700X
NE35941041C0700X
MN308501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical