Provider Demographics
NPI:1881418051
Name:SULLIVAN, LYSHA A
Entity type:Individual
Prefix:
First Name:LYSHA
Middle Name:A
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 1:130 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-2631
Mailing Address - Country:US
Mailing Address - Phone:208-595-4950
Mailing Address - Fax:
Practice Address - Street 1:130 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2631
Practice Address - Country:US
Practice Address - Phone:208-595-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program