Provider Demographics
NPI:1982227765
Name:SULLIVAN, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
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 1:827 JENNY LN
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-7013
Mailing Address - Country:US
Mailing Address - Phone:303-834-0018
Mailing Address - Fax:
Practice Address - Street 1:827 JENNY LN
Practice Address - Street 2:
Practice Address - City:BERTHOUD
Practice Address - State:CO
Practice Address - Zip Code:80513-7013
Practice Address - Country:US
Practice Address - Phone:303-834-0018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014022106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist