MEDICARE: SALLY MARIE SULLIVAN MA, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	12237	OK
2	101Y00000X	Counselor	12237	OK

General Provider Information

NPI Number	:	1154289593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY MARIE SULLIVAN MA, LPC

Provider Business Mailing Address
First Line	:	5151 OAK TIMBER DR
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74131-2654
Country	:	US
Telephone Number	:	918-216-2605
Fax Number	:	918-216-2606

Provider Business Practice Location Address
First Line	:	3150 E 41ST ST STE 108A
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-3739
Country	:	US
Telephone Number	:	918-216-2605
Fax Number	:	918-216-2606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	03/05/2026

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