Healthcare Provider Details

I. General information

NPI: 1487985487
Provider Name (Legal Business Name): NECHEMYAH DONTE'-DEVON SULLIVAN LPC, NCC, ECMHC, CPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 14TH ST NW
ATLANTA GA
30318-5305
US

IV. Provider business mailing address

315 14TH ST NW
ATLANTA GA
30318-5305
US

V. Phone/Fax

Practice location:
  • Phone: 404-691-8880
  • Fax:
Mailing address:
  • Phone: 404-691-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC007137
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC3047
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: