Provider Demographics
NPI:1780339408
Name:SULLIVAN, ABBIE LAURYN
Entity type:Individual
Prefix:
First Name:ABBIE
Middle Name:LAURYN
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 1:1418 ALTO REECE RD
Mailing Address - Street 2:
Mailing Address - City:COFFEE SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36318-5300
Mailing Address - Country:US
Mailing Address - Phone:334-400-3674
Mailing Address - Fax:
Practice Address - Street 1:201 W LEE ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2424
Practice Address - Country:US
Practice Address - Phone:334-475-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician