Provider Demographics
NPI:1013292630
Name:SULLIVAN, ASHLEY (LCSW)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 33963
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-3963
Mailing Address - Country:US
Mailing Address - Phone:971-328-4279
Mailing Address - Fax:971-238-1516
Practice Address - Street 1:6118 SE BELMONT ST STE 317
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1982
Practice Address - Country:US
Practice Address - Phone:971-328-4279
Practice Address - Fax:971-238-1516
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL62451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health