Provider Demographics
NPI:1912120247
Name:SULLIVAN, MICHELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:704-864-7608
Practice Address - Street 1:221 W 26TH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658-2821
Practice Address - Country:US
Practice Address - Phone:704-464-2631
Practice Address - Fax:704-464-5598
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1177106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist