Provider Demographics
NPI:1740367291
Name:SULLIVAN, REBECCA (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N 18TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3410
Mailing Address - Country:US
Mailing Address - Phone:765-423-5361
Mailing Address - Fax:765-742-8272
Practice Address - Street 1:615 N 18TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3410
Practice Address - Country:US
Practice Address - Phone:765-423-5361
Practice Address - Fax:765-742-8272
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340034871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN251500AOtherMEDICARE PROVIDER NUMBER
IN814290Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER