Provider Demographics
NPI:1295978153
Name:SULLIVAN, MARY IRENE (LPCC LPC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:IRENE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPCC LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MABRY RD
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:MO
Mailing Address - Zip Code:63333-2303
Mailing Address - Country:US
Mailing Address - Phone:715-426-8777
Mailing Address - Fax:
Practice Address - Street 1:11 MABRY RD
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:MO
Practice Address - Zip Code:63333-2303
Practice Address - Country:US
Practice Address - Phone:715-426-9877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00181101YP2500X
MO2021009968101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021009968OtherLICENSED PROFESSIONAL COUNSELOR
MNCC00181OtherSTATE OF MINNESOTA BOARD OF BEHAVIORAL HEALTH AND THERAPY