Provider Demographics
NPI:1255053112
Name:SULLIVAN, HEATHER (LPC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SUBLETT RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-8254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:417 GREEN STREET PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3317
Practice Address - Country:US
Practice Address - Phone:678-696-8107
Practice Address - Fax:678-696-8633
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC013228101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional