Provider Demographics
NPI:1780158634
Name:SULLIVAN BAKER, ERIN KATHLEEN (RN M COUN,LPC MS PHD)
Entity type:Individual
Prefix:DR
First Name:ERIN
Middle Name:KATHLEEN
Last Name:SULLIVAN BAKER
Suffix:
Gender:F
Credentials:RN M COUN,LPC MS PHD
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:KATHLEEN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 W BURNSIDE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4916
Mailing Address - Country:US
Mailing Address - Phone:208-233-2051
Mailing Address - Fax:
Practice Address - Street 1:210 W BURNSIDE AVE STE A
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-4916
Practice Address - Country:US
Practice Address - Phone:208-233-2051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-994101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health