Provider Demographics
NPI:1932266137
Name:SULLIVAN, LAURA (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 S INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1648
Mailing Address - Country:US
Mailing Address - Phone:317-831-9764
Mailing Address - Fax:317-831-9764
Practice Address - Street 1:18 S INDIANA ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1648
Practice Address - Country:US
Practice Address - Phone:317-831-9764
Practice Address - Fax:317-831-9764
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001383A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INSULLI-1977OtherCOMPCARE
IN243733OtherVALUE OPTIONS
IN000000238241OtherANTHEM