Provider Demographics
NPI:1801083514
Name:SULLIVAN, MARY LOU (MA COUNSELING MFCC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOU
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA COUNSELING MFCC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOU
Other - Last Name:BACCI VILLAVICENCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1132 SW 13TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1703
Mailing Address - Country:US
Mailing Address - Phone:503-535-3885
Mailing Address - Fax:503-223-6837
Practice Address - Street 1:1132 SW 13TH AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1703
Practice Address - Country:US
Practice Address - Phone:503-535-3885
Practice Address - Fax:503-223-6837
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health