Provider Demographics
NPI:1700656634
Name:SULLIVAN, TIARA SHANNELLE (LCAS-A, LCMHCA)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:SHANNELLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCAS-A, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2382
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-2382
Mailing Address - Country:US
Mailing Address - Phone:910-556-9075
Mailing Address - Fax:910-367-1921
Practice Address - Street 1:3106 S MEMORIAL DR STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-6765
Practice Address - Country:US
Practice Address - Phone:252-916-6048
Practice Address - Fax:252-371-1655
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-28621101YA0400X
NCA19778101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)