Basic Information
| Provider Information | |||||||||
| NPI: | 1063561447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6609 MOUNTAIN BROOK DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276157307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198441649 | ||||||||
| FaxNumber: | 9198441649 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276072934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197849182 | ||||||||
| FaxNumber: | 9197849184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5497 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.