Provider Demographics
NPI:1770568321
Name:SULLIVAN, THOMAS MANN (LCSW LMFT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MANN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LCSW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:645 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-339-1691
Practice Address - Fax:812-337-2438
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003025A1041C0700X, 101YM0800X, 1041C0700X
IN35001314106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN546470FFMedicare ID - Type Unspecified
IN000000077343OtherANTHEM
IN562970QMedicare ID - Type Unspecified