Provider Demographics
NPI:1669909461
Name:SULLIVAN, CORINNE
Entity type:Individual
Prefix:
First Name:CORINNE
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 1:8686 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-1947
Mailing Address - Country:US
Mailing Address - Phone:801-709-0748
Mailing Address - Fax:801-609-9852
Practice Address - Street 1:8686 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-1947
Practice Address - Country:US
Practice Address - Phone:801-709-0748
Practice Address - Fax:801-609-9852
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education